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General NPI Number Information
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NPI Number | 1447048376
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Entity Type | Organization
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Legal Business Name | JON KOELTL DDS, PC
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Dates
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Enumeration Date | 04/29/2025
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Last Update Date | 04/29/2025
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Provider Practice Location Address
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Address Line | 12349 W MCMILLAN RD
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City | BOISE
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State | ID
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Zip | 83713-5052
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Country | US
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Telephone | 208-322-1112
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Fax | 208-322-3928
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Provider Business Mailing Address
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Address Line | 12349 W MCMILLAN RD
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City | BOISE
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State | ID
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Zip | 83713-5052
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Country | US
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Telephone | 208-322-1112
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Fax | 208-322-3928
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. JON MICHAEL KOELTL
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Credential | DDS
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Telephone | 208-322-1112
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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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