Healthcare Provider Details

I. General information

NPI: 1013274661
Provider Name (Legal Business Name): TREASURE VALLEY ORAL AND FACIAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 09/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N. CURTIS RD SUITE 103
BOISE ID
83706
US

IV. Provider business mailing address

1000 N. CURTIS RD SUITE 103
BOISE ID
83706
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-0909
  • Fax: 208-343-6282
Mailing address:
  • Phone: 208-343-0909
  • Fax: 208-343-6282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD4410
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateID

VIII. Authorized Official

Name: COLE W ANDERSON
Title or Position: OWNER
Credential: DMD, MS
Phone: 208-861-1689