Provider Demographics
NPI:1003242769
Name:BRISCOE, DEWAYNE LAVERNE (DDS MD)
Entity Type:Individual
Prefix:DR
First Name:DEWAYNE
Middle Name:LAVERNE
Last Name:BRISCOE
Suffix:
Gender:M
Credentials:DDS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83353-0147
Mailing Address - Country:US
Mailing Address - Phone:208-720-9546
Mailing Address - Fax:
Practice Address - Street 1:404 FAIRWAY LOOP
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:ID
Practice Address - Zip Code:83353
Practice Address - Country:US
Practice Address - Phone:208-720-9546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1661-OS1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery