Provider Demographics
NPI:1013274661
Name:TREASURE VALLEY ORAL AND FACIAL SURGERY PLLC
Entity Type:Organization
Organization Name:TREASURE VALLEY ORAL AND FACIAL SURGERY PLLC
Other - Org Name:BOISE ORAL AND FACIAL SURGERY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLE
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:208-861-1689
Mailing Address - Street 1:1000 N. CURTIS RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706
Mailing Address - Country:US
Mailing Address - Phone:208-343-0909
Mailing Address - Fax:208-343-6282
Practice Address - Street 1:1000 N. CURTIS RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-343-0909
Practice Address - Fax:208-343-6282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-20
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD44101223S0112X
ID1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty