Provider Demographics
NPI:1780048868
Name:INTERMOUNTAIN DENTAL SPECIALISTS, LLC
Entity type:Organization
Organization Name:INTERMOUNTAIN DENTAL SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAHOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-560-9757
Mailing Address - Street 1:3150 SAWTELLE BLVD APT 308
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1445
Mailing Address - Country:US
Mailing Address - Phone:707-490-9125
Mailing Address - Fax:
Practice Address - Street 1:1747 HERITAGE LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-8552
Practice Address - Country:US
Practice Address - Phone:801-841-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6413227-99221223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty