Provider Demographics
NPI:1720259484
Name:JOHN M UKICH
Entity type:Organization
Organization Name:JOHN M UKICH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:UKICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-667-3556
Mailing Address - Street 1:1310 PONDEROSA DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-5073
Mailing Address - Country:US
Mailing Address - Phone:208-255-5410
Mailing Address - Fax:208-255-5420
Practice Address - Street 1:1310 PONDEROSA DR
Practice Address - Street 2:SUITE B
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-5073
Practice Address - Country:US
Practice Address - Phone:208-255-5410
Practice Address - Fax:208-255-5420
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN M UKICH, DDS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD16561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty