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WHITEWATER ORAL SURGERY GROUP PLLC
NPI 1104248053
Dentist - Oral and Maxillofacial Surgery in Boise, ID

Active since January 13, 2014
3003 W MAIN ST STE 130, BOISE, ID 83702(208) 342-7610(208) 344-1799 Get Directions Write a Review

NPPES record last updated: September 4, 2020. Verified against the NPPES registry weekly; last sync: October 25, 2026.

Record update history: Sep 4, 2020, Apr 21, 2020 (2 updates tracked since 2020).

About Whitewater Oral Surgery Group Pllc NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

WHITEWATER ORAL SURGERY GROUP PLLC (NPI 1104248053) is a healthcare organization registered as an oral and maxillofacial surgery in Boise, Idaho and active in the NPI registry since January 2014. The organization lists Kevin Glenn Kempers, Owner, as its authorized official.

NPPES Registry Identity

NPI1104248053
Entity TypeOrganization
Primary Taxonomy1223S0112X
Legal Business NameWHITEWATER ORAL SURGERY GROUP PLLC
Location Address3003 W MAIN ST STE 130Boise, ID 83702-2026
Mailing Address3003 W Main St Ste 130Boise, ID 83702-2026 · (208) 342-7610 · Fax (208) 344-1799
Phone(208) 342-7610
Fax(208) 344-1799
Organization SubpartNo
Authorized OfficialKevin Glenn KempersOwner · (208) 342-7610
Enumeration DateJanuary 13, 2014
Last NPPES UpdateSeptember 4, 20202 updates tracked since enumeration
NPPES CertifiedSeptember 4, 2020
✔ NPI 1104248053 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyDentist · Oral and Maxillofacial SurgeryDental Providers
Taxonomy Code1223S0112X
Licenses✔ Licensed in ID · D3407✔ Licensed in ID · M7750
Definition
An oral and maxillofacial surgery dentist specialized in the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.
3003 W MAIN ST STE 130, Boise, ID 83702
Open in Google Maps ↗

Other Identifiers 2

Medicaid805496900ID
Medicaid805511300ID

Group Practice 1

Group TaxonomyThis provdier is a business group of one or more individual practitioners, all of who practice with the same area of specialization.193400000X MULTIPLE SINGLE SPECIALTY GROUP

Medicare Participation & PECOS CMS

Medicare enrollment and the clinicians who bill Medicare through this organization, from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Whitewater Oral Surgery Group Pllc is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Clinicians Billing Medicare Through This Organization

Medicare enrollment records show 1 clinician reassigns Medicare billing to Whitewater Oral Surgery Group PLLC, which bills Medicare for the services this clinician delivers.

Clinician (1)

Paul Clark, D.M.D, M.D.
Oral Surgery
NPI 1689994923
1502 LOCUST ST N STE 103
Twin Falls, ID 83301
(208) 831-2900
✔ PECOS115 mi

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Whitewater Oral Surgery Group PLLC's NPI number?

The NPI number for Whitewater Oral Surgery Group PLLC is 1104248053. It was assigned to this organization in the NPPES registry on January 13, 2014.

Where is Whitewater Oral Surgery Group PLLC located?

Whitewater Oral Surgery Group PLLC is located at 3003 W Main St Ste 130, Boise, ID 83702. The listed phone number is (208) 342-7610.

What is Whitewater Oral Surgery Group PLLC's specialty?

The primary specialty registered for this NPI is Dentist, specializing in Oral and Maxillofacial Surgery, with taxonomy code 1223S0112X.

Is Whitewater Oral Surgery Group PLLC enrolled in Medicare?

Yes. Whitewater Oral Surgery Group PLLC is registered in the Medicare PECOS enrollment system.

How many clinicians bill Medicare through Whitewater Oral Surgery Group PLLC?

According to the CMS Revalidation Reassignment List (October 2026 release), 1 clinician (Oral Surgery) reassigns their Medicare billing to Whitewater Oral Surgery Group PLLC. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

When was this NPI record last updated?

The NPPES record for Whitewater Oral Surgery Group PLLC was last updated on September 4, 2020. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 6 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.