Provider Demographics
NPI:1902325749
Name:CHERRY LANE KIDS DENTISTRY
Entity Type:Organization
Organization Name:CHERRY LANE KIDS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ELQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-580-7091
Mailing Address - Street 1:121 MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8867
Mailing Address - Country:US
Mailing Address - Phone:208-760-0335
Mailing Address - Fax:
Practice Address - Street 1:1558 N CRESTMONT DR STE A
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2194
Practice Address - Country:US
Practice Address - Phone:208-580-7091
Practice Address - Fax:208-587-2624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4186-PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty