Provider Demographics
NPI:1134240120
Name:KERR, DARCY CAMERON (LD (LICENSED DENTU)
Entity type:Individual
Prefix:MR
First Name:DARCY
Middle Name:CAMERON
Last Name:KERR
Suffix:
Gender:M
Credentials:LD (LICENSED DENTU
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 POCATELLO CREEK RD.
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-238-1100
Mailing Address - Fax:208-233-4933
Practice Address - Street 1:1155 POCATELLO CREEK RD.
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-238-1100
Practice Address - Fax:208-233-4933
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID54122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806654100Medicaid