Healthcare Provider Details

I. General information

NPI: 1114500543
Provider Name (Legal Business Name): TREASURE VALLEY DENTAL ANESTHESIA AND SURGICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N CURTIS RD STE 103
BOISE ID
83706-1345
US

IV. Provider business mailing address

1000 N CURTIS RD STE 103
BOISE ID
83706-1345
US

V. Phone/Fax

Practice location:
  • Phone: 208-994-6227
  • Fax:
Mailing address:
  • Phone: 208-994-6227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State

VIII. Authorized Official

Name: RYAN JUDD
Title or Position: OWNER
Credential: DMD
Phone: 208-343-0909