Healthcare Provider Details

I. General information

NPI: 1194097402
Provider Name (Legal Business Name): RUSSELL GUYMON ORTHODONTICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S WOODRUFF AVE
IDAHO FALLS ID
83401-4322
US

IV. Provider business mailing address

333 S WOODRUFF AVE
IDAHO FALLS ID
83401-4322
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-3500
  • Fax:
Mailing address:
  • Phone: 208-529-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD-4402-OR
License Number StateID

VIII. Authorized Official

Name: DR. RUSSELL J GUYMON
Title or Position: OWNER/ORTHODONTIST
Credential: DDS, MS
Phone: 208-529-3500