Healthcare Provider Details

I. General information

NPI: 1609191253
Provider Name (Legal Business Name): TREVOR GRIFFITTS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8724 N WAYNE DR
HAYDEN ID
83835-5179
US

IV. Provider business mailing address

8724 N WAYNE DR
HAYDEN ID
83835-5179
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-0824
  • Fax: 208-667-1216
Mailing address:
  • Phone: 208-667-0824
  • Fax: 208-667-1216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD-4563-OS
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: