Healthcare Provider Details

I. General information

NPI: 1114304250
Provider Name (Legal Business Name): KHM SURGICAL PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 W IOWA AVE
NAMPA ID
83686-2856
US

IV. Provider business mailing address

339 W IOWA AVE
NAMPA ID
83686-2856
US

V. Phone/Fax

Practice location:
  • Phone: 208-505-1946
  • Fax:
Mailing address:
  • Phone: 208-505-1946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberD4557OS
License Number StateID

VIII. Authorized Official

Name: KAYLYN GREEN
Title or Position: ACCESS MANAGER
Credential:
Phone: 208-505-1946