Provider Demographics
NPI:1932364387
Name:JACK C. KULM DMD PA
Entity Type:Organization
Organization Name:JACK C. KULM DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:KULM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-536-5441
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
Mailing Address - Country:US
Mailing Address - Phone:208-536-5441
Mailing Address - Fax:208-536-5873
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
Practice Address - Country:US
Practice Address - Phone:208-536-5441
Practice Address - Fax:208-536-5873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1679122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002488200Medicaid