Provider Demographics
NPI:1003060591
Name:FACIAL ORAL AND DENTAL IMPLANT SURGERY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:FACIAL ORAL AND DENTAL IMPLANT SURGERY ASSOCIATES, INC.
Other - Org Name:ORAL AND FACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:WILFORD
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-743-1640
Mailing Address - Street 1:3326 4TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4455
Mailing Address - Country:US
Mailing Address - Phone:208-743-1640
Mailing Address - Fax:208-743-1643
Practice Address - Street 1:3326 4TH ST STE 2
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4455
Practice Address - Country:US
Practice Address - Phone:208-743-1640
Practice Address - Fax:208-743-1643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-10
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-40571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808116400Medicaid
ID9212066OtherIDAHO SMILES
ID9212066OtherIDAHO SMILES