Healthcare Provider Details

I. General information

NPI: 1700524105
Provider Name (Legal Business Name): MELANIE JILL NOOMEN D5595
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DEER FLAT RD STE 101
KUNA ID
83634-1337
US

IV. Provider business mailing address

1500 E DEER FLAT RD STE 101
KUNA ID
83634-1337
US

V. Phone/Fax

Practice location:
  • Phone: 208-605-7363
  • Fax:
Mailing address:
  • Phone: 208-605-7363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD5595
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: