Healthcare Provider Details

I. General information

NPI: 1972657922
Provider Name (Legal Business Name): JOHN R UKICH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 LINCOLN WAY SUITE 205
COEUR D ALENE ID
83814-2556
US

IV. Provider business mailing address

1492 E TWISTWOOD DR
HAYDEN LAKE ID
83835-7258
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-3556
  • Fax: 208-664-6814
Mailing address:
  • Phone: 208-667-3556
  • Fax: 208-664-6814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD3742
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: