| NPI | 1780074864 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JEREMY L HIXSON Owner/Provider 208-451-6584 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: ID D-4617-OS) |
| Enumeration Date | 2015-01-28 |
| Last Update Date | 2015-01-28 |