Provider Demographics
NPI:1114255916
Name:ELISON ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:ELISON ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:TURNEY
Authorized Official - Last Name:ELISON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-524-3200
Mailing Address - Street 1:1655 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7467
Mailing Address - Country:US
Mailing Address - Phone:208-529-0634
Mailing Address - Fax:
Practice Address - Street 1:2588 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7515
Practice Address - Country:US
Practice Address - Phone:208-524-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty