Healthcare Provider Details

I. General information

NPI: 1104910199
Provider Name (Legal Business Name): KEVIN MICHAEL ELLIOTT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1097 N JACKSONMILL AVE
KUNA ID
83634-2086
US

IV. Provider business mailing address

1097 N JACKSONMILL AVE
KUNA ID
83634-2086
US

V. Phone/Fax

Practice location:
  • Phone: 208-519-7171
  • Fax: 208-382-3668
Mailing address:
  • Phone: 208-519-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3826
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: