Provider Demographics
NPI:1164567913
Name:MORRISON, JOHN WALLACE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALLACE
Last Name:MORRISON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2301 W A ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-4042
Mailing Address - Country:US
Mailing Address - Phone:208-882-0331
Mailing Address - Fax:208-882-1579
Practice Address - Street 1:2301 W A ST
Practice Address - Street 2:SUITE A
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4042
Practice Address - Country:US
Practice Address - Phone:208-882-0331
Practice Address - Fax:208-882-1579
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3321-OS1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery