Healthcare Provider Details

I. General information

NPI: 1316599558
Provider Name (Legal Business Name): KELSI ANNE WHEELER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 08/29/2019
Certification Date:
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 Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-5071
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: