Healthcare Provider Details

I. General information

NPI: 1710184783
Provider Name (Legal Business Name): CANYON COUNTY ORAL MAXILLOFACIAL SURGERY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 CLOCK TOWER AVE
CALDWELL ID
83607-5006
US

IV. Provider business mailing address

4121 CLOCK TOWER AVE
CALDWELL ID
83607-5006
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-7800
  • Fax:
Mailing address:
  • Phone: 208-459-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberD3848OS
License Number StateID

VIII. Authorized Official

Name: NICHOLAS A MASSOTH
Title or Position: ORAL SURGEON
Credential: DMD
Phone: 208-459-7800