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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