MEDICARE: IKDO STAR LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
2	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1861954026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IKDO STAR LLC

Provider Business Mailing Address
First Line	:	3289 N TOWERBRIDGE WAY
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-8347
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12190 W EVELY PINES LN
Second Line	:
City	:	STAR
State	:	ID
Zip	:	83669-6126
Country	:	US
Telephone Number	:	208-884-4466
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL D PAYNE
Credential	:	DMD
Telephone Number	:	208-884-4466

Provider Enumeration Date	:	04/04/2019
Last Update Date	:	05/08/2020

Similar Medicare Providers

1194463778 — JAKOB RODGERS DDS
Practice Location Address:

12190 W EVELY PINES LN
STAR, ID
83669-6126

Practice Phone: 208-996-3003
Practice Fax:

1093842031 — DR. LINDA M HANEY MD
Practice Location Address:

10717 W STATE ST
STAR, ID
83669

Practice Phone: 208-302-6300
Practice Fax: 208-302-6355

1831148105 — DR. JEFFREY PAUL GRAVIET O.D.
Practice Location Address:

170 S SENECA SPRINGS WAY , STE 100
STAR, ID
83669-5938

Practice Phone: 208-898-4112
Practice Fax:

1679679088 — MR. BRIAN DAVID NICHOLS MPT ATC
Practice Location Address:

9652 W STATE STREET
STAR, ID
83669-5858

Practice Phone: 208-286-0766
Practice Fax: 208-286-0768

1194822528 — LINDSEY E. DECLOSS M.S.P.T.
Practice Location Address:

9652 W STATE ST
STAR, ID
83669-5858

Practice Phone: 208-286-0766
Practice Fax:

1043380769 — NICHOLS THERAPY GROUP PC
Practice Location Address:

9652 W STATE STREET
STAR, ID
83669-5858

Practice Phone: 208-286-0766
Practice Fax: 208-286-0768

Directions to “IKDO STAR LLC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.