Provider Demographics
NPI:1710184783
Name:CANYON COUNTY ORAL MAXILLOFACIAL SURGERY, INC
Entity Type:Organization
Organization Name:CANYON COUNTY ORAL MAXILLOFACIAL SURGERY, INC
Other - Org Name:CANYON COUNTY ORAL MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MASSOTH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-459-7800
Mailing Address - Street 1:4121 CLOCK TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-5006
Mailing Address - Country:US
Mailing Address - Phone:208-459-7800
Mailing Address - Fax:
Practice Address - Street 1:4121 CLOCK TOWER AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-5006
Practice Address - Country:US
Practice Address - Phone:208-459-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3848OS1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID10149985OtherREGENCE BLUE SHIELD
ID1783151OtherUNITED CONCORDIA
ID6L859OtherBLUE CROSS OF ID