=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265535066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALAN R. PEARCE DDS, MD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 N WHITLEY DR SUITE 3
-----------------------------------------------------
City | FRUITLAND
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83619-2704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-452-4808
-----------------------------------------------------
Fax | 208-452-4816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 N WHITLEY DR SUITE 3
-----------------------------------------------------
City | FRUITLAND
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83619-2704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-452-4808
-----------------------------------------------------
Fax | 208-452-4816
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORAL & MAXILLONFACIAL SURGEON
-----------------------------------------------------
Name | ALAN ROYCE PEARCE
-----------------------------------------------------
Credential | DDS, MD, PA
-----------------------------------------------------
Telephone | 208-452-4808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | D-3344-OS
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------