Provider Demographics
NPI:1487238689
Name:TABLE ROCK ORAL SURGERY PLLC
Entity type:Organization
Organization Name:TABLE ROCK ORAL SURGERY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:208-412-0637
Mailing Address - Street 1:403 S 11TH ST STE 320
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6968
Mailing Address - Country:US
Mailing Address - Phone:208-375-0191
Mailing Address - Fax:
Practice Address - Street 1:403 S 11TH ST STE 320
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6968
Practice Address - Country:US
Practice Address - Phone:208-375-0191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-12
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery