Provider Demographics
NPI:1811670631
Name:PARKCENTER ORAL AND MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:PARKCENTER ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUPP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-553-6813
Mailing Address - Street 1:3190 E BARBER VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716
Mailing Address - Country:US
Mailing Address - Phone:208-715-5219
Mailing Address - Fax:208-504-2771
Practice Address - Street 1:3190 E BARBER VALLEY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716
Practice Address - Country:US
Practice Address - Phone:208-715-5219
Practice Address - Fax:208-504-2771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-09
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty