Healthcare Provider Details

I. General information

NPI: 1588868442
Provider Name (Legal Business Name): IDAHO ORAL & MAXILLOFACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 FALLS AVE
TWIN FALLS ID
83301-3314
US

IV. Provider business mailing address

590 FALLS AVE
TWIN FALLS ID
83301-3314
US

V. Phone/Fax

Practice location:
  • Phone: 208-733-1182
  • Fax: 208-733-3341
Mailing address:
  • Phone: 208-733-1182
  • Fax: 208-733-3341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberD3944-OS
License Number StateID

VIII. Authorized Official

Name: DR. TIMOTHY TED HOPKINS
Title or Position: OWNER
Credential: D.D.S.,MS
Phone: 208-733-1182