Healthcare Provider Details

I. General information

NPI: 1609785930
Provider Name (Legal Business Name): EAGLE NATURAL DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E STATE ST STE 100
EAGLE ID
83616-5941
US

IV. Provider business mailing address

700 E STATE ST STE 100
EAGLE ID
83616-5941
US

V. Phone/Fax

Practice location:
  • Phone: 208-631-7485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: HIEDI HANNA WOOD
Title or Position: OFFICE MANAGER
Credential:
Phone: 406-200-5239