Whitewater Oral Surgery Group Pllc | |
3003 W Main St Ste 130 Boise ID 83702-2026 | |
(208) 342-7610 | |
(208) 344-1799 |
Full Name | Whitewater Oral Surgery Group Pllc |
---|---|
Speciality | Dentist |
Location | 3003 W Main St Ste 130, Boise, Idaho |
Authorized Official Name and Position | Kevin Glenn Kempers (OWNER) |
Authorized Official Contact | 2083427610 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
Whitewater Oral Surgery Group Pllc 3003 W Main St Ste 130 Boise ID 83702-2026 Ph: (208) 342-7610 | Whitewater Oral Surgery Group Pllc 3003 W Main St Ste 130 Boise ID 83702-2026 Ph: (208) 342-7610 |
NPI Number | 1104248053 |
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Provider Enumeration Date | 01/13/2014 |
Last Update Date | 09/04/2020 |
Medicare PECOS PAC ID | 4789009473 |
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Medicare Enrollment ID | O20200928002448 |
Identifier | Type | State | Issuer |
---|---|---|---|
1104248053 | NPI | - | NPPES |
805496900 | Medicaid | ID | |
805511300 | Medicaid | ID |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
1223S0112X | Dentist - Oral And Maxillofacial Surgery | D3407 (Idaho) | Primary |
1223S0112X | Dentist - Oral And Maxillofacial Surgery | M7750 (Idaho) | Secondary |
Provider Name | Paul Clark |
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Provider Type | Practitioner - Oral Surgery |
Provider Identifiers | NPI Number: 1689994923 PECOS PAC ID: 1456772060 Enrollment ID: I20200608002472 |
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