Provider Demographics
NPI:1073720009
Name:MAGIC VALLEY ORAL SURGERY
Entity Type:Organization
Organization Name:MAGIC VALLEY ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERPRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-734-3562
Mailing Address - Street 1:590 FALLS AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3314
Mailing Address - Country:US
Mailing Address - Phone:208-734-3562
Mailing Address - Fax:208-736-8339
Practice Address - Street 1:590 FALLS AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3314
Practice Address - Country:US
Practice Address - Phone:208-734-3562
Practice Address - Fax:208-736-8339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD16581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T44225Medicare UPIN
1203482Medicare ID - Type Unspecified