Healthcare Provider Details

I. General information

NPI: 1568095883
Provider Name (Legal Business Name): FACIAL TRAUMA ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2020
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N CURTIS RD STE 103
BOISE ID
83706-1345
US

IV. Provider business mailing address

1000 N CURTIS RD STE 103
BOISE ID
83706-1345
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-0909
  • Fax:
Mailing address:
  • Phone: 208-343-0909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. COLE W ANDERSON
Title or Position: MEMBER
Credential: DMD
Phone: 208-343-0909