Healthcare Provider Details

I. General information

NPI: 1306973862
Provider Name (Legal Business Name): RODNEY H HILLAM DDS MS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 S HOLMES AVE
IDAHO FALLS ID
83404-7981
US

IV. Provider business mailing address

3325 S HOLMES AVE
IDAHO FALLS ID
83404-7981
US

V. Phone/Fax

Practice location:
  • Phone: 206-524-1800
  • Fax: 208-524-1890
Mailing address:
  • Phone: 206-524-1800
  • Fax: 208-524-1890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number918
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2019
License Number StateID

VIII. Authorized Official

Name: RODNEY H HILLAM
Title or Position: OWNER PRESIDENT
Credential: DDS MS PA
Phone: 208-524-1800