Provider Demographics
NPI:1972333565
Name:EAGLE ANESTHESIA & ORAL SURGERY PLLC
Entity type:Organization
Organization Name:EAGLE ANESTHESIA & ORAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST ANESTHESIOLOGIST
Authorized Official - Prefix:
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 1:37 W ARCHERFIELD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7721
Mailing Address - Country:US
Mailing Address - Phone:503-679-9797
Mailing Address - Fax:
Practice Address - Street 1:5266 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0945
Practice Address - Country:US
Practice Address - Phone:503-679-9797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Single Specialty