Healthcare Provider Details

I. General information

NPI: 1225289390
Provider Name (Legal Business Name): RODNEY H. HILLAM DDS, MS, PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 10/07/2008
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
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-1800
  • Fax: 208-524-1890
Mailing address:
  • Phone: 208-524-1800
  • Fax: 208-524-1890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number113353500
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2019
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: