Provider Demographics
NPI:1447048376
Name:JON KOELTL DDS, PC
Entity type:Organization
Organization Name:JON KOELTL DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KOELTL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-322-1112
Mailing Address - Street 1:12349 W MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5052
Mailing Address - Country:US
Mailing Address - Phone:208-322-1112
Mailing Address - Fax:208-322-3928
Practice Address - Street 1:12349 W MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5052
Practice Address - Country:US
Practice Address - Phone:208-322-1112
Practice Address - Fax:208-322-3928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental