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General NPI Number Information
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NPI Number | 1417701400
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Entity Type | Individual
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Provider Name | KELTON CRONQUIST DMD, MS
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Gender | Male
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Dates
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Enumeration Date | 04/16/2024
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Last Update Date | 04/16/2024
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Provider Practice Location Address
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Address Line | 1200 W CHERRY LN
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City | MERIDIAN
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State | ID
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Zip | 83642-4930
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Country | US
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Telephone | 208-898-0000
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Fax |
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Provider Business Mailing Address
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Address Line | 840 N TULLSHIRE WAY
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City | EAGLE
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State | ID
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Zip | 83616-3305
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Country | US
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Telephone | 435-760-0323
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | D-5605
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License Number State | ID
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