Provider Demographics
NPI:1700932704
Name:JURKOVICH, WAYNE L (DDS)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:L
Last Name:JURKOVICH
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 1:611 BANK ST
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:ID
Mailing Address - Zip Code:83873-2226
Mailing Address - Country:US
Mailing Address - Phone:208-556-8171
Mailing Address - Fax:208-556-8171
Practice Address - Street 1:611 BANK ST
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:ID
Practice Address - Zip Code:83873-2226
Practice Address - Country:US
Practice Address - Phone:208-556-8171
Practice Address - Fax:208-556-8171
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD18321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice