Healthcare Provider Details

I. General information

NPI: 1336036474
Provider Name (Legal Business Name): TETON OMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2025
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 BRIDGEPORT DR
IDAHO FALLS ID
83402-3370
US

IV. Provider business mailing address

780 BRIDGEPORT DR
IDAHO FALLS ID
83402-3370
US

V. Phone/Fax

Practice location:
  • Phone: 208-932-4600
  • Fax: 208-932-4601
Mailing address:
  • Phone: 208-932-4600
  • Fax: 208-932-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: MAKELL CLAY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 208-932-4600