Dewayne Laverne Briscoe, DDS MD
Individual provider Active NPI Oral and Maxillofacial Surgery (Dentist) · Sun Valley, ID
NPI 1003242769 · NPPES record last updated Sep 25, 2013
Key facts
- NPI
- 1003242769
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Oral and Maxillofacial Surgery (Dentist) 1223S0112X
- License
- D-1661-OS (ID)
- Practice address
- 404 Fairway Loop
Sun Valley, ID 83353 - Phone
- (208) 720-9546
- NPI assigned
- Sep 25, 2013
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D-1661-OS | ID | MD | Oral and Maxillofacial Surgery (Dentist) |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Oral and Maxillofacial Surgery (Dentist) | 1223S0112X | D-1661-OS | ID | Yes |
Addresses
Primary practice location
404 Fairway Loop
Sun Valley, ID 83353
Mailing address
PO Box 147
Sun Valley, ID 83353-0147
Phone (208) 720-9546
Other providers in Sun Valley, ID
All providers in Sun Valley, ID · Oral and Maxillofacial Surgery (Dentist) in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 25, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.