Healthcare Provider Details

I. General information

NPI: 1154805786
Provider Name (Legal Business Name): JMJ NAMPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 12TH AVE RD
NAMPA ID
83686
US

IV. Provider business mailing address

3289 N TOWERBRIDGE WAY
MERIDIAN ID
83646-8347
US

V. Phone/Fax

Practice location:
  • Phone: 208-468-9191
  • Fax:
Mailing address:
  • Phone: 208-884-4466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL PAYNE D. PAYNE
Title or Position: PRESIDENT
Credential: DMD
Phone: 208-884-4466