Provider Demographics
NPI:1730941279
Name:JAMES ORAL AND MAXILLOFACIAL SURGERY PLLC
Entity type:Organization
Organization Name:JAMES ORAL AND MAXILLOFACIAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-705-9652
Mailing Address - Street 1:2677 E 17TH ST STE 600
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2677 E 17TH ST STE 600
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6619
Practice Address - Country:US
Practice Address - Phone:208-705-9652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-30
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty