Provider Demographics
NPI:1023398716
Name:COEUR D' ALENE ORAL SURGERY
Entity type:Organization
Organization Name:COEUR D' ALENE ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-667-0655
Mailing Address - Street 1:1027 E SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4152
Mailing Address - Country:US
Mailing Address - Phone:208-667-0655
Mailing Address - Fax:208-667-5745
Practice Address - Street 1:1027 E SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4152
Practice Address - Country:US
Practice Address - Phone:208-667-0655
Practice Address - Fax:208-667-5745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1578-OS1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty