MEDICARE: EAGLE ANESTHESIA & ORAL SURGERY PLLC

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	1223D0004X	Dental Anesthesiology

General Provider Information

NPI Number	:	1972333565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE ANESTHESIA & ORAL SURGERY PLLC

Provider Business Mailing Address
First Line	:	37 W ARCHERFIELD ST STE 100
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-7721
Country	:	US
Telephone Number	:	503-679-9797
Fax Number	:

Provider Business Practice Location Address
First Line	:	5266 N EAGLE RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-0945
Country	:	US
Telephone Number	:	503-679-9797
Fax Number	:

Authorized Official
Title or Position	:	DENTIST ANESTHESIOLOGIST
Name	:	RYAN JUDD
Credential	:	DMD
Telephone Number	:	503-679-9797

Provider Enumeration Date	:	08/07/2024
Last Update Date	:	08/07/2024

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