Healthcare Provider Details

I. General information

NPI: 1124892773
Provider Name (Legal Business Name): INNOVATIVE SLEEP & TMJ CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 W MCMILLAN RD
MERIDIAN ID
83646-6892
US

IV. Provider business mailing address

1720 W MCMILLAN RD
MERIDIAN ID
83646-6892
US

V. Phone/Fax

Practice location:
  • Phone: 208-216-6110
  • Fax:
Mailing address:
  • Phone: 208-216-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL B SMITH
Title or Position: MANAGER
Credential: DMD
Phone: 208-870-6288