MEDICARE: JORDAN E. HIGHAM PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	D-4205-PD	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1710186432	OTHER	ID	SOLO PRACTICE NPI

General Provider Information

NPI Number	:	1437595881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JORDAN E. HIGHAM PA

Provider Business Mailing Address
First Line	:	929 S UTAH AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-3322
Country	:	US
Telephone Number	:	208-529-2199
Fax Number	:

Provider Business Practice Location Address
First Line	:	929 S UTAH AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-3322
Country	:	US
Telephone Number	:	208-529-2199
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. JORDAN ELLISON HIGHAM
Credential	:	DDS
Telephone Number	:	208-529-2199

Provider Enumeration Date	:	05/13/2013
Last Update Date	:	05/13/2013

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