NPIMap

Organization Active NPI

Idaho Oral Surgery PLLC

  • Exclusive Provider Organization
  • Fruitland, ID
National Provider Identifier
1912172958
Registry record updated Apr 19, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Exclusive Provider OrganizationTaxonomy code 302F00000X
License
D3949OS Issued in ID
Legal business name
IDAHO ORAL SURGERY PLLC
Practice address
1820 N Whitley Dr
Fruitland, ID 83619-2163
Phone
(208) 452-4808
Fax
(208) 452-6617
NPI assigned
Apr 29, 2008
Last updated
Apr 19, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 19, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ryan David Hillam, DDSNPI 1992880132
Title
Surgeon
Phone
(208) 452-4808

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Exclusive Provider Organization 302F00000X D3949OS ID Primary

Addresses

Primary practice location

1820 N Whitley Dr
Fruitland, ID 83619-2163

Mailing address

1820 N Whitley Dr
Fruitland, ID 83619-2163
Phone (208) 452-4808

Other identifiers 2

IdentifierTypeStateIssuer
241342MedicaidOR
807651700MedicaidID

Other names 1

  • CENTER FOR ORAL & FACIAL SURGERY Former legal business name

National Provider Directory

National Provider Directory

Locations

1820 N Whitley Dr
Fruitland, ID 83619
Phone (208) 452-4808

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1209427200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1271635200000",
    "number": "1912172958",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1820 N WHITLEY DR",
            "city": "FRUITLAND",
            "state": "ID",
            "postal_code": "836192163",
            "telephone_number": "208-452-4808",
            "fax_number": "208-452-6617"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1820 N WHITLEY DR",
            "city": "FRUITLAND",
            "state": "ID",
            "postal_code": "836192163",
            "telephone_number": "208-452-4808",
            "fax_number": "208-452-6617"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO ORAL SURGERY PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-29",
        "last_updated": "2010-04-19",
        "status": "A",
        "authorized_official_last_name": "HILLAM",
        "authorized_official_first_name": "RYAN",
        "authorized_official_middle_name": "DAVID",
        "authorized_official_title_or_position": "SURGEON",
        "authorized_official_telephone_number": "208-452-4808",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "302F00000X",
            "taxonomy_group": "",
            "desc": "Exclusive Provider Organization",
            "state": "ID",
            "license": "D3949OS",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "241342",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "807651700",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CENTER FOR ORAL & FACIAL SURGERY",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Fruitland, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 19, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.