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General NPI Number Information
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NPI Number | 1912172958
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Entity Type | Organization
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Legal Business Name | IDAHO ORAL SURGERY PLLC
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Dates
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Enumeration Date | 04/29/2008
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Last Update Date | 04/19/2010
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Provider Practice Location Address
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Address Line | 1820 N WHITLEY DR
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City | FRUITLAND
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State | ID
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Zip | 83619-2163
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Country | US
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Telephone | 208-452-4808
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Fax | 208-452-6617
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Provider Business Mailing Address
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Address Line | 1820 N WHITLEY DR
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City | FRUITLAND
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State | ID
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Zip | 83619-2163
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Country | US
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Telephone | 208-452-4808
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Fax | 208-452-6617
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Authorized Official
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Title or Position | SURGEON
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Name | RYAN DAVID HILLAM
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Credential | DDS
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Telephone | 208-452-4808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | D3949OS
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License Number State | ID
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