Healthcare Provider Details

I. General information

NPI: 1487494795
Provider Name (Legal Business Name): KIERSTIN ELIZABETH SHAHTOUT DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIERSTIN ELIZABETH EVENSON

II. Dates (important events)

Enumeration Date: 05/27/2024
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1067 S WELLS ST
MERIDIAN ID
83642-7997
US

IV. Provider business mailing address

3090 N LOCHNESS AVE
MERIDIAN ID
83646-6790
US

V. Phone/Fax

Practice location:
  • Phone: 208-895-8486
  • Fax:
Mailing address:
  • Phone: 406-788-0848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN-DEN-LIC-30828
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: