Provider Demographics
NPI:1346824422
Name:MAGIC VALLEY DENTAL ANESTHESIA PLLC
Entity Type:Organization
Organization Name:MAGIC VALLEY DENTAL ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-679-9797
Mailing Address - Street 1:3245 S BRANDENBERG AVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1411 FALLS AVE E STE 1000C
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3459
Practice Address - Country:US
Practice Address - Phone:208-734-7415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty