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General NPI Number Information
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NPI Number | 1720259484
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Entity Type | Organization
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Legal Business Name | JOHN M UKICH
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Dates
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Enumeration Date | 03/20/2008
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Last Update Date | 03/20/2008
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Provider Practice Location Address
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Address Line | 1310 PONDEROSA DR SUITE B
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City | SANDPOINT
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State | ID
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Zip | 83864-5073
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Country | US
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Telephone | 208-255-5410
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Fax | 208-255-5420
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Provider Business Mailing Address
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Address Line | 1310 PONDEROSA DR SUITE B
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City | SANDPOINT
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State | ID
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Zip | 83864-5073
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Country | US
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Telephone | 208-255-5410
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Fax | 208-255-5420
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOHN M UKICH
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Credential |
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Telephone | 208-667-3556
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | D1656
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License Number State | ID
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