Healthcare Provider Details

I. General information

NPI: 1255968053
Provider Name (Legal Business Name): DEVAN MICHAEL MUNK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 W MAIN ST STE 130
BOISE ID
83702-2026
US

IV. Provider business mailing address

3003 W MAIN ST STE 130
BOISE ID
83702-2026
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-7610
  • Fax:
Mailing address:
  • Phone: 208-342-7610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD5596
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD5596
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: