Healthcare Provider Details

I. General information

NPI: 1699949750
Provider Name (Legal Business Name): BOISE ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6363 W EMERALD ST SUITE 103
BOISE ID
83704-8783
US

IV. Provider business mailing address

6363 W EMERALD ST SUITE 103
BOISE ID
83704-8783
US

V. Phone/Fax

Practice location:
  • Phone: 208-376-4550
  • Fax: 208-376-4552
Mailing address:
  • Phone: 208-376-4550
  • Fax: 208-376-4552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD-3407
License Number StateID

VIII. Authorized Official

Name: DR. KEVIN KEMPERS
Title or Position: OWNER
Credential: DDS/MD
Phone: 208-376-4550