Provider Demographics
NPI:1841643533
Name:DENTAL PARTNERS USTICK PLLC
Entity type:Organization
Organization Name:DENTAL PARTNERS USTICK PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:KLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-446-8400
Mailing Address - Street 1:4403 E USTICK RD # 104
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-6802
Mailing Address - Country:US
Mailing Address - Phone:208-994-3033
Mailing Address - Fax:208-475-6599
Practice Address - Street 1:4403 E USTICK RD # 104
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6802
Practice Address - Country:US
Practice Address - Phone:208-994-3033
Practice Address - Fax:208-475-6599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4634261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental