Provider Demographics
NPI:1629470141
Name:IDAHO DENTAL ANESTHESIA PLLC
Entity Type:Organization
Organization Name:IDAHO DENTAL ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST ANESTHESIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-679-9797
Mailing Address - Street 1:37 W ARCHERFIELD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6587
Mailing Address - Country:US
Mailing Address - Phone:208-391-2894
Mailing Address - Fax:
Practice Address - Street 1:37 W ARCHERFIELD ST STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6587
Practice Address - Country:US
Practice Address - Phone:208-391-2894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-46131223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty