Provider Demographics
NPI:1588868442
Name:IDAHO ORAL & MAXILLOFACIAL SURGERY, PC
Entity type:Organization
Organization Name:IDAHO ORAL & MAXILLOFACIAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:TED
Authorized Official - Last Name:HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:208-733-1182
Mailing Address - Street 1:590 FALLS AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3314
Mailing Address - Country:US
Mailing Address - Phone:208-733-1182
Mailing Address - Fax:208-733-3341
Practice Address - Street 1:590 FALLS AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3314
Practice Address - Country:US
Practice Address - Phone:208-733-1182
Practice Address - Fax:208-733-3341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3944-OS1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty