Provider Demographics
NPI:1790202810
Name:WHITEWATER WOODRIVER ORAL SURGERY
Entity Type:Organization
Organization Name:WHITEWATER WOODRIVER ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-788-5308
Mailing Address - Street 1:400 S MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-8856
Mailing Address - Country:US
Mailing Address - Phone:208-788-5308
Mailing Address - Fax:
Practice Address - Street 1:400 S MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8856
Practice Address - Country:US
Practice Address - Phone:208-788-5308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery