Healthcare Provider Details

I. General information

NPI: 1063330892
Provider Name (Legal Business Name): KOOTENAI FAMILY DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 LINCOLN WAY STE 200
COEUR D ALENE ID
83814-2360
US

IV. Provider business mailing address

1420 LINCOLN WAY STE 200
COEUR D ALENE ID
83814-2360
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-8283
  • Fax: 208-667-0794
Mailing address:
  • Phone: 208-664-8283
  • Fax: 208-667-0794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEXIS LAROSE
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 208-664-8283