Provider Demographics
NPI:1649453275
Name:FACIAL & ORAL SURGERY ASSOCIATES, INC.
Entity type:Organization
Organization Name:FACIAL & ORAL SURGERY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDE
Authorized Official - Middle Name:
Authorized Official - Last Name:STUART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-232-2807
Mailing Address - Street 1:PO BOX 6033
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-6033
Mailing Address - Country:US
Mailing Address - Phone:208-232-2807
Mailing Address - Fax:208-232-8118
Practice Address - Street 1:165 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4146
Practice Address - Country:US
Practice Address - Phone:208-232-2807
Practice Address - Fax:208-232-8118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD30161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID190005336OtherRAILROAD MEDICARE
ID190009031OtherRAILROAD MEDICARE
ID805112100Medicaid
ID805112200Medicaid
ID805177600Medicaid
IDU32580Medicare UPIN
ID1140355Medicare PIN
ID1203327Medicare PIN
G49612Medicare UPIN
ID805112200Medicaid
ID1376582Medicare PIN
ID1204023Medicare PIN
ID805177600Medicaid