1346824422 NPI number — MAGIC VALLEY DENTAL ANESTHESIA PLLC

Table of content: WAEL ALI ELSAMMAN MD (NPI 1831419126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346824422 NPI number — MAGIC VALLEY DENTAL ANESTHESIA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGIC VALLEY DENTAL ANESTHESIA PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346824422
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3245 S BRANDENBERG AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGLE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83616-4413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1411 FALLS AVE E STE 1000C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-3459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-7415
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2021

Additional Information

Authorized Official

Authorized Official Last Name:
JUDD
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
503-679-9797

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223D0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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