Healthcare Provider Details

I. General information

NPI: 1003060591
Provider Name (Legal Business Name): FACIAL ORAL AND DENTAL IMPLANT SURGERY ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3326 4TH ST STE 2
LEWISTON ID
83501-4455
US

IV. Provider business mailing address

3326 4TH ST STE 2
LEWISTON ID
83501-4455
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-1640
  • Fax: 208-743-1643
Mailing address:
  • Phone: 208-743-1640
  • Fax: 208-743-1643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD-4057
License Number StateID

VIII. Authorized Official

Name: DR. STEPHEN WILFORD HOLM
Title or Position: OWNER
Credential: DMD
Phone: 208-743-1640