Healthcare Provider Details

I. General information

NPI: 1942317664
Provider Name (Legal Business Name): KOOTENAI FAMILY DENTAL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 LINCOLN WAY SUITE 200
COEUR DALENE ID
83814
US

IV. Provider business mailing address

1420 LINCOLN WAY SUITE 200
COEUR DALENE ID
83814
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 Code122300000X
TaxonomyDentist
License Number3794
License Number StateID

VIII. Authorized Official

Name: DR. ROBERT L WILDER
Title or Position: DENTIST
Credential: DDS
Phone: 208-664-8283