Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D1499 | ID |
NPI | 1003919986 |
---|---|
Provider Name | Mr. John Stanley Kriz |
First Address | Boise, ID 83704-8600 |
Second Address | Boise, ID 83704-8600 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
6G587 | BLUE CROSS (01) | ID |