Healthcare Provider Details

I. General information

NPI: 1447428735
Provider Name (Legal Business Name): DAVID A KENT MD CHARTERED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 02/08/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5516 N GLENWOOD ST STE B
GARDEN CITY ID
83714-9219
US

IV. Provider business mailing address

5561 N GLENWOOD ST STE B
GARDEN CITY ID
83714-1336
US

V. Phone/Fax

Practice location:
  • Phone: 208-863-0860
  • Fax:
Mailing address:
  • Phone: 208-863-0860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM5609
License Number StateID

VIII. Authorized Official

Name: DAVID A KENT
Title or Position: PRESIDENT
Credential:
Phone: 208-863-0860