Provider Demographics
NPI:1679749212
Name:KORTH B. ELLIOTT, DDS
Entity type:Organization
Organization Name:KORTH B. ELLIOTT, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KORTH
Authorized Official - Middle Name:B
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-378-9280
Mailing Address - Street 1:8219 NORTHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7131
Mailing Address - Country:US
Mailing Address - Phone:208-378-9280
Mailing Address - Fax:
Practice Address - Street 1:8219 NORTHVIEW ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7131
Practice Address - Country:US
Practice Address - Phone:208-378-9280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-04
Last Update Date:2008-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1996122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002652300Medicaid