Healthcare Provider Details

I. General information

NPI: 1689346736
Provider Name (Legal Business Name): CDA KIDS DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1341 N NORTHWOOD CENTER CT STE B
COEUR D ALENE ID
83814-2471
US

IV. Provider business mailing address

1110 E SILVER PINE RD
COLBERT WA
99005-5125
US

V. Phone/Fax

Practice location:
  • Phone: 208-500-2204
  • Fax: 208-619-4619
Mailing address:
  • Phone:
  • Fax:

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: DR. DEVIN MORIN
Title or Position: MANAGING MEMBER/SOLE MEMBER
Credential: DMD
Phone: 502-712-9561