Healthcare Provider Details

I. General information

NPI: 1073720009
Provider Name (Legal Business Name): MAGIC VALLEY ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 08/22/2020
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: 208-734-3562
  • Fax: 208-736-8339
Mailing address:
  • Phone: 208-734-3562
  • Fax: 208-736-8339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD1658
License Number StateID

VIII. Authorized Official

Name: DR. VINCENT LYNN WILLIAMS
Title or Position: OWNERPRESIDENT
Credential: DMD
Phone: 208-734-3562