Healthcare Provider Details

I. General information

NPI: 1053584284
Provider Name (Legal Business Name): MICHAEL R BAILEY MD DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 S 11TH ST SUITE 300
BOISE ID
83702-6968
US

IV. Provider business mailing address

403 S 11TH ST SUITE 300
BOISE ID
83702-6968
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-9115
  • Fax: 208-344-9113
Mailing address:
  • Phone: 208-344-9115
  • Fax: 208-344-9113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD3165/M6325
License Number StateID

VIII. Authorized Official

Name: MICHAEL R BAILEY
Title or Position: OWNER
Credential: MD DDS
Phone: 208-344-9115