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General NPI Number Information
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NPI Number | 1649453275
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Entity Type | Organization
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Legal Business Name | FACIAL & ORAL SURGERY ASSOCIATES, INC.
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Dates
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Enumeration Date | 12/05/2007
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Last Update Date | 06/16/2010
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Provider Practice Location Address
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Address Line | 165 N 14TH AVE
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City | POCATELLO
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State | ID
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Zip | 83201-4146
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Country | US
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Telephone | 208-232-2807
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Fax | 208-232-8118
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Provider Business Mailing Address
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Address Line | PO BOX 6033
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City | POCATELLO
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State | ID
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Zip | 83205-6033
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Country | US
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Telephone | 208-232-2807
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Fax | 208-232-8118
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | MRS. WENDE STUART
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Credential |
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Telephone | 208-232-2807
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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 | D3016
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License Number State | ID
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