Healthcare Provider Details

I. General information

NPI: 1104248053
Provider Name (Legal Business Name): WHITEWATER ORAL SURGERY GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 W MAIN ST STE 130
BOISE ID
83702-2026
US

IV. Provider business mailing address

3003 W MAIN ST STE 130
BOISE ID
83702-2026
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-7610
  • Fax: 208-344-1799
Mailing address:
  • Phone: 208-342-7610
  • Fax: 208-344-1799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberM7750
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD3407
License Number StateID

VIII. Authorized Official

Name: DR. KEVIN GLENN KEMPERS
Title or Position: OWNER
Credential: MD, DDS
Phone: 208-342-7610