Individual
JOHN M UKICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
1717 LINCOLN WAY, SUITE 205, COEUR D ALENE, ID 83814-2556
(208) 667-3556
(208) 664-6814
Mailing address
11493 N EASTSHORE DR, HAYDEN LAKE, ID 83835-9091
(208) 667-3556
(208) 664-6814
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
D1626
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010009296
BLUE SHIELD ID#
ID
01
—
526225
UNITED CONCORDIA #
ID
01
—
6G660
BLU CROSS ID#
ID
01
—
D1656
STATE LISENCE #
ID
Enumeration date
01/23/2007
Last updated
07/09/2007
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