| NPI | 1164615084 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RILEY JARED HICKS Owner 208-528-6000 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: ID 3314) |
| Enumeration Date | 2007-08-23 |
| Last Update Date | 2007-08-23 |