Healthcare Provider Details

I. General information

NPI: 1942111307
Provider Name (Legal Business Name): PONDERAY NEWCO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476653 HIGHWAY 95 STE 1
PONDERAY ID
83852-9816
US

IV. Provider business mailing address

476653 HIGHWAY 95 STE 1
PONDERAY ID
83852-9816
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-6771
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KORY WILSON
Title or Position: CEO
Credential: DDS
Phone: 208-661-7879