Healthcare Provider Details

I. General information

NPI: 1710050943
Provider Name (Legal Business Name): RICHARD E FERGUSON D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 STILSON RD SUITE C
BOISE ID
83703-5119
US

IV. Provider business mailing address

813 STILSON RD SUITE 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:
Title or Position:
Credential:
Phone: