Healthcare Provider Details

I. General information

NPI: 1841852563
Provider Name (Legal Business Name): JENNAFER KEDISH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 E CENTRAL DR
MERIDIAN ID
83642-7991
US

IV. Provider business mailing address

1297 W PINE AVE APT D104
MERIDIAN ID
83642-1928
US

V. Phone/Fax

Practice location:
  • Phone: 208-373-1855
  • Fax:
Mailing address:
  • Phone: 208-819-2409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD5053
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: