=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437684099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HILLAM ORTHODONTICS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2017
-----------------------------------------------------
Last Update Date | 04/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3325 S. HOLMES AVE.
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-524-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3325 S HOLMES AVE
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-7981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-524-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. JORDAN RODNEY HILLAM
-----------------------------------------------------
Credential | D.D.S., M.S.D.
-----------------------------------------------------
Telephone | 208-524-1800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 4648
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------