Healthcare Provider Details

I. General information

NPI: 1831774611
Provider Name (Legal Business Name): DR. JAMES ROCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2021
Last Update Date: 03/13/2021
Certification Date: 03/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11092 W PETUNIA DR
BOISE ID
83709-7098
US

IV. Provider business mailing address

10400 W OVERLAND RD
BOISE ID
83709-1433
US

V. Phone/Fax

Practice location:
  • Phone: 208-891-0725
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License NumberD-5186-RD
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: