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General NPI Number Information
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NPI Number | 1003242769
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Entity Type | Individual
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Provider Name | DEWAYNE LAVERNE BRISCOE DDS MD
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Gender | Male
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Dates
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Enumeration Date | 09/25/2013
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Last Update Date | 09/25/2013
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Provider Practice Location Address
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Address Line | 404 FAIRWAY LOOP
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City | SUN VALLEY
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State | ID
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Zip | 83353
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Country | US
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Telephone | 208-720-9546
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 147
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City | SUN VALLEY
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State | ID
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Zip | 83353-0147
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Country | US
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Telephone | 208-720-9546
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | D-1661-OS
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License Number State | ID
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