Provider Demographics
NPI:1801679287
Name:CHUBBUCK KIDZ DENTAL PC
Entity type:Organization
Organization Name:CHUBBUCK KIDZ DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MAGDALENA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-272-7558
Mailing Address - Street 1:371 E CHUBBUCK RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202
Mailing Address - Country:US
Mailing Address - Phone:208-425-7690
Mailing Address - Fax:
Practice Address - Street 1:371 E CHUBBUCK RD
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202
Practice Address - Country:US
Practice Address - Phone:208-358-8871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-17
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty