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General NPI Number Information
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NPI Number | 1861954026
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Entity Type | Organization
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Legal Business Name | IKDO STAR LLC
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Dates
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Enumeration Date | 04/04/2019
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Last Update Date | 05/08/2020
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Provider Practice Location Address
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Address Line | 12190 W EVELY PINES LN
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City | STAR
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State | ID
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Zip | 83669-6126
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Country | US
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Telephone | 208-884-4466
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Fax |
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Provider Business Mailing Address
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Address Line | 3289 N TOWERBRIDGE WAY
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City | MERIDIAN
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State | ID
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Zip | 83646-8347
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL D PAYNE
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Credential | DMD
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Telephone | 208-884-4466
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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