Healthcare Provider Details

I. General information

NPI: 1366824484
Provider Name (Legal Business Name): KIP T KATSEANES DMD MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 N EAGLE RD
BOISE ID
83713
US

IV. Provider business mailing address

6019 N EAGLE RD
BOISE ID
83713
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-2777
  • Fax: 208-377-3075
Mailing address:
  • Phone: 208-377-2777
  • Fax: 208-377-3075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD5185PE
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: