Provider Demographics
NPI:1497083638
Name:PALOUSE ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:PALOUSE ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:MORRISN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-882-0331
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3321-OS261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1164567913OtherNPI-PERSONAL