Healthcare Provider Details

I. General information

NPI: 1437641735
Provider Name (Legal Business Name): KOALBY BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13219 W PERSIMMON LN
BOISE ID
83713-1986
US

IV. Provider business mailing address

13219 W PERSIMMON LN
BOISE ID
83713-1986
US

V. Phone/Fax

Practice location:
  • Phone: 208-373-0018
  • Fax: 208-378-9676
Mailing address:
  • Phone: 208-373-0018
  • Fax: 208-378-9676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD4924
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: