# JASON CHAMPAGNE IDAHO 4, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Blue Heron Dental
- **Organization subpart:** No

## Provider details

- **NPI number:** 1508614033
- **Authorized official:** JASON CHAMPAGNE DDS (OWNER)
- **Authorized official phone:** (775) 359-3934

## Contact information

- **Practice address:** 345 W BOBWHITE CT, BOISE, ID 83706-3982
- **Practice address phone:** (208) 345-1383
- **Mailing address:** PO BOX 2070, SPARKS, NV 89432-2070

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 05/09/2024
- **Last updated:** 05/09/2024