MEDICARE: IDAHO CENTER FOR ORAL AND FACIAL SURGERY

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	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center	D-4276-OS	ID

General Provider Information

NPI Number	:	1558675298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDAHO CENTER FOR ORAL AND FACIAL SURGERY

Provider Business Mailing Address
First Line	:	177 VISTA DR
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83201-5824
Country	:	US
Telephone Number	:	208-232-0232
Fax Number	:	208-232-2044

Provider Business Practice Location Address
First Line	:	177 VISTA DR
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83201-5824
Country	:	US
Telephone Number	:	208-232-0232
Fax Number	:	208-232-2044

Authorized Official
Title or Position	:	SURGEON
Name	:	DR. JEFFREY C DABELL
Credential	:	DMD, MD
Telephone Number	:	208-232-0232

Provider Enumeration Date	:	08/05/2010
Last Update Date	:	11/30/2010

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Directions to “IDAHO CENTER FOR ORAL AND FACIAL SURGERY ” Practice Location

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