1912172958 NPI number — IDAHO ORAL SURGERY PLLC

Table of content: (NPI 1912172958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912172958 NPI number — IDAHO ORAL SURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDAHO ORAL SURGERY 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:
6
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:
1912172958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1820 N WHITLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRUITLAND
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83619-2163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-452-4808
Provider Business Mailing Address Fax Number:
208-452-6617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1820 N WHITLEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-4808
Provider Business Practice Location Address Fax Number:
208-452-6617
Provider Enumeration Date:
04/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HILLAM
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
SURGEON
Authorized Official Telephone Number:
208-452-4808

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X , with the licence number:  D3949OS , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 241342 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807651700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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