Healthcare Provider Details

I. General information

NPI: 1558406405
Provider Name (Legal Business Name): COEUR D ALENE DENTURE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 N 4TH ST
COEUR D ALENE ID
83814
US

IV. Provider business mailing address

1119 N 4TH ST
COEUR D ALENE ID
83814
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-8997
  • Fax: 208-666-1746
Mailing address:
  • Phone: 208-667-8997
  • Fax: 208-666-1746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122400000X
TaxonomyDenturist
License NumberLD43
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberLD42
License Number StateID

VIII. Authorized Official

Name: JACQUELINE KAY NEFF
Title or Position: DENTURIST CO OWNER
Credential: LD43
Phone: 208-667-8997