Healthcare Provider Details

I. General information

NPI: 1265340103
Provider Name (Legal Business Name): AVONDALE DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1683 E MILES AVE
HAYDEN LAKE ID
83835-9109
US

IV. Provider business mailing address

1015 W IRONWOOD DR
COEUR D ALENE ID
83814-2602
US

V. Phone/Fax

Practice location:
  • Phone: 208-772-4066
  • Fax:
Mailing address:
  • Phone: 208-500-5854
  • 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: KORY WILSON
Title or Position: CEO
Credential: DDS
Phone: 208-661-7879