Provider Demographics
NPI:1487093704
Name:DIVINE, KATHERINE ANNE (DDS)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:ANNE
Last Name:DIVINE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 E CENTRAL DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7991
Mailing Address - Country:US
Mailing Address - Phone:208-373-1860
Mailing Address - Fax:208-373-1856
Practice Address - Street 1:1311 E CENTRAL DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7991
Practice Address - Country:US
Practice Address - Phone:208-373-1860
Practice Address - Fax:208-373-1856
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4500-SS122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist