Healthcare Provider Details

I. General information

NPI: 1962336693
Provider Name (Legal Business Name): NORTHWEST ORAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3190 E BARBER VALLEY DR
BOISE ID
83716-4735
US

IV. Provider business mailing address

1670 S SPRING VALLEY LN
MERIDIAN ID
83642-9094
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-9115
  • Fax: 208-344-9113
Mailing address:
  • Phone: 208-344-9115
  • Fax: 208-344-9113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SYRUS HAGHIGHI
Title or Position: OWNER
Credential: DDS
Phone: 208-344-9115