Healthcare Provider Details

I. General information

NPI: 1710186432
Provider Name (Legal Business Name): JORDAN HIGHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 05/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 S UTAH AVE
IDAHO FALLS ID
83402-3322
US

IV. Provider business mailing address

370 N STATE ST BOX 683
SHELLEY ID
83274-1141
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-2199
  • Fax:
Mailing address:
  • Phone: 208-360-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD-4205
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: