MEDICARE: RICHARD E FERGUSON D.D.S., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	D-1669-PE	ID

General Provider Information

NPI Number	:	1710050943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD E FERGUSON D.D.S., M.S.

Provider Business Mailing Address
First Line	:	813 STILSON RD
Second Line	:	SUITE C
City	:	BOISE
State	:	ID
Zip	:	83703-5119
Country	:	US
Telephone Number	:	208-344-0908
Fax Number	:	208-338-0306

Provider Business Practice Location Address
First Line	:	813 STILSON RD
Second Line	:	SUITE C
City	:	BOISE
State	:	ID
Zip	:	83703-5119
Country	:	US
Telephone Number	:	208-344-0908
Fax Number	:	208-338-0306

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/09/2007

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