Organization
IKDO STATE STREET LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JAYCIE BIRCH (OFFICE MANAGER)
(208) 388-1111
Entity
Organization
Contact information
Practice address
9209 W STATE ST, GARDEN CITY, ID 83714
(208) 388-1111
Mailing address
9209 W STATE ST, GARDEN CITY, ID 83714
(208) 388-1111
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
—
—
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
—
—
Other
Enumeration date
09/18/2018
Last updated
09/18/2018
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