Provider Demographics
NPI:1457704009
Name:KSS DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:KSS DENTAL GROUP PLLC
Other - Org Name:FAIRVIEW DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:L
Authorized Official - Last Name:STUCKI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-459-3388
Mailing Address - Street 1:329 E LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4863
Mailing Address - Country:US
Mailing Address - Phone:208-459-3388
Mailing Address - Fax:208-453-9295
Practice Address - Street 1:329 E LOGAN ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4863
Practice Address - Country:US
Practice Address - Phone:208-459-3388
Practice Address - Fax:208-453-9295
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KSS DENTAL GROUP PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD33151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty