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General NPI Number Information
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NPI Number | 1235565003
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Entity Type | Organization
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Legal Business Name | KEVIN MUDROW DDS PLLC
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Dates
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Enumeration Date | 09/24/2013
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Last Update Date | 09/24/2013
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Provider Practice Location Address
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Address Line | 333 S WOODRUFF AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83401-4322
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Country | US
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Telephone | 208-524-2036
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Fax |
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Provider Business Mailing Address
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Address Line | 333 S WOODRUFF AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83401
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Country | US
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Telephone | 208-524-2036
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Fax |
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Authorized Official
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Title or Position | OWNER/GENERAL DENTIST
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Name | DR. KEVIN RICHARD MUDROW
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Credential | DDS
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Telephone | 208-524-2036
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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