Provider Demographics
NPI:1710050943
Name:FERGUSON, RICHARD E (DDS, MS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 STILSON RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5119
Mailing Address - Country:US
Mailing Address - Phone:208-344-0908
Mailing Address - Fax:208-338-0306
Practice Address - Street 1:813 STILSON RD
Practice Address - Street 2:SUITE C
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5119
Practice Address - Country:US
Practice Address - Phone:208-344-0908
Practice Address - Fax:208-338-0306
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1669-PE1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1204114Medicare ID - Type UnspecifiedMEDICARE