Healthcare Provider Details

I. General information

NPI: 1326812637
Provider Name (Legal Business Name): JHKK PERIODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2352 S TITANIUM PL
MERIDIAN ID
83642-6867
US

IV. Provider business mailing address

2352 S TITANIUM PL
MERIDIAN ID
83642-6867
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-2777
  • Fax: 208-377-3075
Mailing address:
  • Phone: 208-377-2777
  • Fax: 208-377-3075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. KIP KATSEANES
Title or Position: CO-OWNER/DOCTOR
Credential: DMD, MSD
Phone: 208-377-2777