Provider Demographics
NPI:1962629527
Name:CORNERSTONE FAMILY & COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:CORNERSTONE FAMILY & COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-382-3558
Mailing Address - Street 1:PO BOX 498
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:ID
Mailing Address - Zip Code:83611-0498
Mailing Address - Country:US
Mailing Address - Phone:208-382-3558
Mailing Address - Fax:208-382-3668
Practice Address - Street 1:220 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:ID
Practice Address - Zip Code:83611
Practice Address - Country:US
Practice Address - Phone:208-382-3558
Practice Address - Fax:208-382-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHD38261223G0001X
IDD32801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010155075OtherDR NEWTON REGENCE BS
ID6P003OtherDR NEWTON BC BS
ID6P005OtherDR. ELLIOTT BC BS
ID000010156002OtherDR ELLIOTT REGENCE BS