Healthcare Provider Details

I. General information

NPI: 1093165524
Provider Name (Legal Business Name): CODY WAID L.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1833 N LAKES PL
MERIDIAN ID
83646-1921
US

IV. Provider business mailing address

505 1ST ST STE A
IDAHO FALLS ID
83401-3929
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-1887
  • Fax:
Mailing address:
  • Phone: 208-346-1887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberLD-111
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: