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General NPI Number Information
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NPI Number | 1629470141
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Entity Type | Organization
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Legal Business Name | IDAHO DENTAL ANESTHESIA PLLC
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Dates
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Enumeration Date | 09/17/2014
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Last Update Date | 08/12/2020
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Provider Practice Location Address
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Address Line | 37 W ARCHERFIELD ST STE 100
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City | MERIDIAN
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State | ID
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Zip | 83646-6587
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Country | US
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Telephone | 208-391-2894
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Fax |
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Provider Business Mailing Address
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Address Line | 37 W ARCHERFIELD ST STE 100
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City | MERIDIAN
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State | ID
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Zip | 83646-6587
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Country | US
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Telephone | 208-391-2894
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Fax |
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Authorized Official
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Title or Position | DENTIST ANESTHESIOLOGIST
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Name | DR. RYAN W JUDD
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Credential | DMD
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Telephone | 503-679-9797
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0004X
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Taxonomy Name | Dental Anesthesiology
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License Number | D-4613
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License Number State | ID
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