Healthcare Provider Details

I. General information

NPI: 1487910733
Provider Name (Legal Business Name): TIMOTHY TRACY OBRIEN DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 S 11TH ST STE 320
BOISE ID
83702-6968
US

IV. Provider business mailing address

403 S 11TH ST STE 320
BOISE ID
83702-6968
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-0191
  • Fax:
Mailing address:
  • Phone: 208-375-0191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD-5013-OS
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: