# EAGLE ORAL SURGERY AND DENTAL IMPLANT CENTER PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1780074864
- **Authorized official:** JEREMY L HIXSON DMD (OWNER/PROVIDER)
- **Authorized official phone:** (208) 451-6584

## Contact information

- **Practice address:** 197 W STATE ST, EAGLE, ID 83616-4959
- **Practice address phone:** (208) 995-2865
- **Mailing address:** 197 W STATE ST, EAGLE, ID 83616-4959
- **Mailing address phone:** (208) 995-2865

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | D-4617-OS | ID | Yes |

## Other

- **Enumeration date:** 01/28/2015
- **Last updated:** 01/28/2015