Organization
FACIAL & ORAL SURGERY ASSOCIATES, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. WENDE STUART (OFFICE ADMINISTRATOR)
(208) 232-2807
Entity
Organization
Contact information
Practice address
165 N 14TH AVE, POCATELLO, ID 83201-4146
(208) 232-2807
(208) 232-8118
Mailing address
PO BOX 6033, POCATELLO, ID 83205-6033
(208) 232-2807
(208) 232-8118
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
D3016
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
190005336
RAILROAD MEDICARE
ID
01
—
190009031
RAILROAD MEDICARE
ID
05
—
805112100
—
ID
05
—
805112200
—
ID
05
—
805177600
—
ID
Enumeration date
12/05/2007
Last updated
06/16/2010
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