Healthcare Provider Details

I. General information

NPI: 1164567913
Provider Name (Legal Business Name): JOHN WALLACE MORRISON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 W A ST SUITE A
MOSCOW ID
83843-4042
US

IV. Provider business mailing address

2301 W A ST SUITE A
MOSCOW ID
83843-4042
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-0331
  • Fax: 208-882-1579
Mailing address:
  • Phone: 208-882-0331
  • Fax: 208-882-1579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD-3321-OS
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: