Provider Demographics
NPI:1558675298
Name:IDAHO CENTER FOR ORAL AND FACIAL SURGERY
Entity Type:Organization
Organization Name:IDAHO CENTER FOR ORAL AND FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:DABELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:208-232-0232
Mailing Address - Street 1:177 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5824
Mailing Address - Country:US
Mailing Address - Phone:208-232-0232
Mailing Address - Fax:208-232-2044
Practice Address - Street 1:177 VISTA DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5824
Practice Address - Country:US
Practice Address - Phone:208-232-0232
Practice Address - Fax:208-232-2044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4276-OS261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery