| NPI | 1134789845 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KAREN SHAW Practice Manager 208-344-9115 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QS0112X Clinic/Center, Oral and Maxillofacial Surgery |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery |
| Enumeration Date | 2019-06-14 |
| Last Update Date | 2026-02-09 |