Provider Demographics
NPI:1699949750
Name:BOISE ORAL AND MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:BOISE ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEMPERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS/MD
Authorized Official - Phone:208-376-4550
Mailing Address - Street 1:6363 W EMERALD ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8783
Mailing Address - Country:US
Mailing Address - Phone:208-376-4550
Mailing Address - Fax:208-376-4552
Practice Address - Street 1:6363 W EMERALD ST
Practice Address - Street 2:SUITE 103
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8783
Practice Address - Country:US
Practice Address - Phone:208-376-4550
Practice Address - Fax:208-376-4552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-34071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT44223Medicare UPIN
ID1203437Medicare PIN