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General NPI Number Information
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NPI Number | 1265340103
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Entity Type | Organization
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Legal Business Name | AVONDALE DENTAL PLLC
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Dates
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Enumeration Date | 08/31/2026
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Last Update Date | 08/31/2026
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Provider Practice Location Address
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Address Line | 1683 E MILES AVE
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City | HAYDEN LAKE
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State | ID
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Zip | 83835-9109
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Country | US
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Telephone | 208-772-4066
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Fax |
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Provider Business Mailing Address
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Address Line | 1015 W IRONWOOD DR
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2602
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Country | US
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Telephone | 208-500-5854
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KORY WILSON
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Credential | DDS
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Telephone | 208-661-7879
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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