Provider Demographics
NPI:1902950041
Name:UKICH, JOHN M (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:UKICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:11493 N EASTSHORE DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN LAKE
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9091
Mailing Address - Country:US
Mailing Address - Phone:208-667-3556
Mailing Address - Fax:208-664-6814
Practice Address - Street 1:1717 LINCOLN WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2556
Practice Address - Country:US
Practice Address - Phone:208-667-3556
Practice Address - Fax:208-664-6814
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDD16261223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID526225OtherUNITED CONCORDIA #
IDD1656OtherSTATE LISENCE #
ID000010009296OtherBLUE SHIELD ID#
ID6G660OtherBLU CROSS ID#