=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164567913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN WALLACE MORRISON D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2301 W A ST SUITE A
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-4042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-882-0331
-----------------------------------------------------
Fax | 208-882-1579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2301 W A ST SUITE A
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-4042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-882-0331
-----------------------------------------------------
Fax | 208-882-1579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | D-3321-OS
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------