Newly Listed Provider — this NPI profile has been added to the NPI registry within the last 90 days.
KOOTENAI FAMILY DENTAL PLLC
Complete NPI Record 1063330892
Clinic/Center - Dental in Coeur D Alene, ID
Active since July 08, 2026
Complete NPI Dataset
This page contains the complete raw NPPES record for Kootenai Family Dental Pllc (NPI 1063330892), a clinic/center organization in Coeur D Alene, ID. All 29 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.
Use the tools below to filter fields by category, search within the record, or jump straight to a specific field. You can download the full record as a CSV, JSON, Markdown or text file, or filter first and export only the fields you need. The Print Clean Summary button produces a printer-friendly copy of the record.
Registry File Document Utilities
- NPI: 1063330892 Field 1/29
- The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
- Entity Type Code: 2 Field 2/29
- Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
- Employer Identification Number EIN: Not available Field 3/29
- The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
- Provider Organization Name Legal Business Name: KOOTENAI FAMILY DENTAL PLLC Field 4/29
- The name of the organization provider. If the provider is an organization, this is the legal business name.
- Provider First Line Business Mailing Address: 1420 LINCOLN WAY STE 200 Field 5/29
- The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
- Provider Business Mailing Address City Name: COEUR D ALENE Field 6/29
- The city name in the mailing address of the provider being identified.
- Provider Business Mailing Address State Name: ID Field 7/29
- The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
- Provider Business Mailing Address Postal Code: 838142360 Field 8/29
- The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
- Provider Business Mailing Address Country Code If outside U S : US Field 9/29
- The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
- Provider Business Mailing Address Telephone Number: 2086648283 Field 10/29
- The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
- Provider Business Mailing Address Fax Number: 2086670794 Field 11/29
- The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
- Provider First Line Business Practice Location Address: 1420 LINCOLN WAY STE 200 Field 12/29
- The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
- Provider Business Practice Location Address City Name: COEUR D ALENE Field 13/29
- The city name in the location address of the provider being identified.
- Provider Business Practice Location Address State Name: ID Field 14/29
- The State code in the location of the provider being identified.
- Provider Business Practice Location Address Postal Code: 838142360 Field 15/29
- The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
- Provider Business Practice Location Address Country Code If outside U S : US Field 16/29
- The country code in the location address of the provider being identified.
- Provider Business Practice Location Address Telephone Number: 2086648283 Field 17/29
- The telephone number associated with the location address of the provider being identified.
- Provider Business Practice Location Address Fax Number: 2086670794 Field 18/29
- The fax number associated with the location address of the provider being identified.
- Authorized Official Last Name: LAROSE Field 21/29
- The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
- Authorized Official First Name: ALEXIS Field 22/29
- The first name of the authorized official.
- Authorized Official Title or Position: OWNER/DENTIST Field 23/29
- The title or position of the authorized official.
- Authorized Official Telephone Number: 2086648283 Field 24/29
- The 10-position telephone number of the authorized official.
- Healthcare Provider Taxonomy Code 1: 261QD0000X Field 25/29
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 1: Y Field 26/29
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Is Organization Subpart: N Field 27/29
- Indicates whether the provider is a subpart of a larger organization. This is a single-character code: "Y" means the entity is an organizational subpart, while "N" means it is not. Subparts typically include hospital departments, clinics, or other distinct units that fall under a parent organization.
- Authorized Official Credential Text: DDS Field 28/29
- The professional credential(s) of the authorized official listed on the provider's NPI record. Examples include MD (Doctor of Medicine), DO (Doctor of Osteopathy), RN (Registered Nurse), DDS (Doctor of Dental Surgery), PhD, or other recognized designations that reflect the official's qualifications.
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