Organization
MERIDIAN DENTAL, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. ALLYSON KOUSKY (INSURANCE MANAGER)
(208) 888-4711
Entity
Organization
Contact information
Practice address
780 W CHERRY LN, MERIDIAN, ID 83642-1617
(208) 888-4711
(208) 888-0308
Mailing address
780 W CHERRY LN, MERIDIAN, ID 83642-1617
(208) 888-4711
(208) 888-0308
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
134932
TRI-CARE
ID
Enumeration date
08/01/2006
Last updated
08/22/2020
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