Healthcare Provider Details

I. General information

NPI: 1023356540
Provider Name (Legal Business Name): KELLY A. SILVA, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 S 2ND ST
SAINT MARIES ID
83861-2209
US

IV. Provider business mailing address

132 S 2ND ST
SAINT MARIES ID
83861-2209
US

V. Phone/Fax

Practice location:
  • Phone: 120-824-5391
  • Fax: 120-824-5551
Mailing address:
  • Phone: 120-824-5391
  • Fax: 120-824-5551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3897
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLY A SILVA
Title or Position: PRESIDENT
Credential: DDS
Phone: 208-245-3912