Healthcare Provider Details

I. General information

NPI: 1346824422
Provider Name (Legal Business Name): MAGIC VALLEY DENTAL ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1411 FALLS AVE E STE 1000C
TWIN FALLS ID
83301-3459
US

IV. Provider business mailing address

3245 S BRANDENBERG AVE
EAGLE ID
83616-4413
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-7415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN JUDD
Title or Position: OWNER
Credential: DMD
Phone: 503-679-9797