Healthcare Provider Details

I. General information

NPI: 1770769325
Provider Name (Legal Business Name): KENT J ALLEN/ SHANNON WIDMIER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 01/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 CENTER ST W
KIMBERLY ID
83341
US

IV. Provider business mailing address

702 CENTER STREET WEST PO BOX B
KIMBERLY ID
83341
US

V. Phone/Fax

Practice location:
  • Phone: 208-423-6444
  • Fax: 208-423-6903
Mailing address:
  • Phone: 208-423-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD1767
License Number StateCA

VIII. Authorized Official

Name: DR. KENT J ALLEN
Title or Position: OWNER
Credential: D.D.S.
Phone: 208-423-6444