Provider Demographics
NPI:1104248053
Name:WHITEWATER ORAL SURGERY GROUP PLLC
Entity type:Organization
Organization Name:WHITEWATER ORAL SURGERY GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:KEMPERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:208-342-7610
Mailing Address - Street 1:3003 W MAIN ST STE 130
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-2026
Mailing Address - Country:US
Mailing Address - Phone:208-342-7610
Mailing Address - Fax:208-344-1799
Practice Address - Street 1:3003 W MAIN ST STE 130
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-2026
Practice Address - Country:US
Practice Address - Phone:208-342-7610
Practice Address - Fax:208-344-1799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-13
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM77501223S0112X
IDD34071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805496900Medicaid
ID805511300Medicaid