Healthcare Provider Details

I. General information

NPI: 1588827125
Provider Name (Legal Business Name): RICHARD E. FERGUSON D.D.S.,M.S. PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 STILSON RD STE C
BOISE ID
83703-5119
US

IV. Provider business mailing address

813 STILSON RD STE C
BOISE ID
83703-5119
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-0908
  • Fax: 208-338-0306
Mailing address:
  • Phone: 208-344-0908
  • Fax: 208-338-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD-1669-PE
License Number StateID

VIII. Authorized Official

Name: DR. RICHARD E. FERGUSON
Title or Position: OWNER
Credential: D.D.S., M.S.
Phone: 208-344-0908