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General NPI Number Information
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NPI Number | 1841643533
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Entity Type | Organization
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Legal Business Name | DENTAL PARTNERS USTICK PLLC
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Dates
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Enumeration Date | 07/18/2016
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Last Update Date | 07/18/2016
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Provider Practice Location Address
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Address Line | 4403 E USTICK RD # 104
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City | CALDWELL
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State | ID
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Zip | 83605-6802
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Country | US
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Telephone | 208-994-3033
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Fax | 208-475-6599
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Provider Business Mailing Address
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Address Line | 4403 E USTICK RD # 104
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City | CALDWELL
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State | ID
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Zip | 83605-6802
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Country | US
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Telephone | 208-994-3033
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Fax | 208-475-6599
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Authorized Official
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Title or Position | DR
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Name | DR. KLINT KELLER
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Credential | DDS
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Telephone | 208-446-8400
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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 | D4634
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License Number State | ID
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