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General NPI Number Information
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NPI Number | 1073720009
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Entity Type | Organization
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Legal Business Name | MAGIC VALLEY ORAL SURGERY
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 590 FALLS AVE
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City | TWIN FALLS
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State | ID
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Zip | 83301-3314
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Country | US
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Telephone | 208-734-3562
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Fax | 208-736-8339
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Provider Business Mailing Address
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Address Line | 590 FALLS AVE
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City | TWIN FALLS
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State | ID
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Zip | 83301-3314
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Country | US
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Telephone | 208-734-3562
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Fax | 208-736-8339
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Authorized Official
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Title or Position | OWNERPRESIDENT
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Name | DR. VINCENT LYNN WILLIAMS
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Credential | DMD
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Telephone | 208-734-3562
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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 | D1658
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License Number State | ID
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