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General NPI Number Information
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NPI Number | 1124892773
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Entity Type | Organization
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Legal Business Name | INNOVATIVE SLEEP & TMJ CENTER PLLC
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Dates
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Enumeration Date | 11/14/2023
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Last Update Date | 11/21/2024
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Provider Practice Location Address
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Address Line | 1720 W MCMILLAN RD
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City | MERIDIAN
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State | ID
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Zip | 83646-6892
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Country | US
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Telephone | 208-216-6110
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Fax |
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Provider Business Mailing Address
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Address Line | 1720 W MCMILLAN RD
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City | MERIDIAN
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State | ID
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Zip | 83646-6892
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Country | US
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Telephone | 208-216-6110
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. RANDALL B SMITH
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Credential | DMD
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Telephone | 208-870-6288
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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