| NPI | 1912172958 |
|---|---|
| Former Legal Business Name | CENTER FOR ORAL & FACIAL SURGERY |
| Entity Type | Organization |
| Authorized Contact | RYAN DAVID HILLAM Surgeon 208-452-4808 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: ID D3949OS) |
| Enumeration Date | 2008-04-29 |
| Last Update Date | 2010-04-19 |