Healthcare Provider Details

I. General information

NPI: 1811670631
Provider Name (Legal Business Name): PARKCENTER ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3190 E BARBER VALLEY DR
BOISE ID
83716
US

IV. Provider business mailing address

3190 E BARBER VALLEY DR
BOISE ID
83716
US

V. Phone/Fax

Practice location:
  • Phone: 208-715-5219
  • Fax: 208-504-2771
Mailing address:
  • Phone: 208-715-5219
  • Fax: 208-504-2771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. STUART J RUPP
Title or Position: OWNER
Credential: DMD
Phone: 208-553-6813