Healthcare Provider Details

I. General information

NPI: 1609478080
Provider Name (Legal Business Name): ANDREW JOSEPH HIGHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 11/11/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 S UTAH AVE
IDAHO FALLS ID
83402-3322
US

IV. Provider business mailing address

1027 N 1200 E
SHELLEY ID
83274-5364
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-2199
  • Fax:
Mailing address:
  • Phone: 208-589-0939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD-5213
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: