1790202810 NPI number — WHITEWATER WOODRIVER ORAL SURGERY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790202810 NPI number — WHITEWATER WOODRIVER ORAL SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITEWATER WOODRIVER ORAL SURGERY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790202810
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 S MAIN ST STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAILEY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83333-8856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-788-5308
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 S MAIN ST STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAILEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83333-8856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-788-5308
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BERRY
Authorized Official First Name:
MARIE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
208-788-5308

Provider Taxonomy Codes

  • Taxonomy code: 261QS0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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