Provider Demographics
NPI:1649535493
Name:FUNK, JEREMIAH MCKELL (DDS)
Entity type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:MCKELL
Last Name:FUNK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:ID
Mailing Address - Zip Code:83355-5038
Mailing Address - Country:US
Mailing Address - Phone:208-536-5441
Mailing Address - Fax:
Practice Address - Street 1:410 N IDAHO ST
Practice Address - Street 2:
Practice Address - City:WENDELL
Practice Address - State:ID
Practice Address - Zip Code:83355-5038
Practice Address - Country:US
Practice Address - Phone:208-536-5441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4555122300000X
TX28007122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist