Provider Demographics
NPI:1336443977
Name:PEACH, KARL DOUGLAS (DDS, MS)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:DOUGLAS
Last Name:PEACH
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 E. POLSTON AVE.
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854
Mailing Address - Country:US
Mailing Address - Phone:208-777-1010
Mailing Address - Fax:208-773-0667
Practice Address - Street 1:1145 E POLSTON AVE.
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854
Practice Address - Country:US
Practice Address - Phone:208-777-1010
Practice Address - Fax:208-773-0667
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-053061223X0400X
WADE000072911223X0400X
CA372731223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics