Provider Demographics
NPI:1679743470
Name:THE KIDS' DENTIST, PLLC
Entity type:Organization
Organization Name:THE KIDS' DENTIST, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MEADORS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-938-6343
Mailing Address - Street 1:2300 W EVEREST LN
Mailing Address - Street 2:SUITE 125
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5925
Mailing Address - Country:US
Mailing Address - Phone:208-938-6343
Mailing Address - Fax:208-884-5048
Practice Address - Street 1:2300 W EVEREST LN
Practice Address - Street 2:SUITE 125
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5925
Practice Address - Country:US
Practice Address - Phone:208-938-6343
Practice Address - Fax:208-884-5048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3120PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty