Provider Demographics
NPI:1942463187
Name:KUNA DENTAL PC
Entity Type:Organization
Organization Name:KUNA DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:CROFT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-922-4149
Mailing Address - Street 1:927 N LINDER RD
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-1274
Mailing Address - Country:US
Mailing Address - Phone:208-922-4149
Mailing Address - Fax:208-922-4140
Practice Address - Street 1:927 N LINDER RD
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-1274
Practice Address - Country:US
Practice Address - Phone:208-922-4149
Practice Address - Fax:208-922-4140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-32821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804236800Medicaid