Provider Demographics
NPI:1790896645
Name:HUMPHREYS, PAIGE
Entity Type:Individual
Prefix:MR
First Name:PAIGE
Middle Name:
Last Name:HUMPHREYS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-734-3312
Mailing Address - Fax:208-734-5036
Practice Address - Street 1:325 MARTIN ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4563
Practice Address - Country:US
Practice Address - Phone:208-734-0451
Practice Address - Fax:208-734-0452
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD37071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6O035Medicare UPIN