Provider Demographics
NPI:1265532261
Name:KOOTENAI DENTAL GROUP, LLC
Entity type:Organization
Organization Name:KOOTENAI DENTAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DELWYN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-762-8750
Mailing Address - Street 1:555 W. CANFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7892
Mailing Address - Country:US
Mailing Address - Phone:208-762-8750
Mailing Address - Fax:208-762-2530
Practice Address - Street 1:555 W. CANFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7892
Practice Address - Country:US
Practice Address - Phone:208-762-8750
Practice Address - Fax:208-762-2530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDID030491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty