Healthcare Provider Details

I. General information

NPI: 1437684099
Provider Name (Legal Business Name): HILLAM ORTHODONTICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 S. HOLMES AVE.
IDAHO FALLS ID
83404
US

IV. Provider business mailing address

3325 S HOLMES AVE
IDAHO FALLS ID
83404-7981
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-1800
  • Fax:
Mailing address:
  • Phone: 208-524-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4648
License Number StateID

VIII. Authorized Official

Name: DR. JORDAN RODNEY HILLAM
Title or Position: ORTHODONTIST
Credential: D.D.S., M.S.D.
Phone: 208-524-1800