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Organization
CANYON COUNTY ORAL MAXILLOFACIAL SURGERY, INC
Active
Organization
CANYON COUNTY ORAL MAXILLOFACIAL SURGERY, INC
Active
Other names
Canyon County Oral Maxillofacial Surgery
Organization subpart
No
Provider details
NPI number
Authorized official
NICHOLAS A MASSOTH DMD (ORAL SURGEON)
(208) 459-7800
Entity
Organization
Contact information
Practice address
4121 CLOCK TOWER AVE, CALDWELL, ID 83607-5006
(208) 459-7800
Mailing address
4121 CLOCK TOWER AVE, CALDWELL, ID 83607-5006
(208) 459-7800
Taxonomy
Speciality
Code
Description
License number
State
1223P0106X
Oral and Maxillofacial Pathology Dentistry
Primary
D3848OS
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10149985
REGENCE BLUE SHIELD
ID
01
—
1783151
UNITED CONCORDIA
ID
01
—
6L859
BLUE CROSS OF ID
ID
Enumeration date
07/02/2007
Last updated
07/10/2007
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