Healthcare Provider Details

I. General information

NPI: 1508155623
Provider Name (Legal Business Name): KATHLEEN A BEAUDRY D.M.D., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 7TH AVE S 412 SCHOOL OF DENTISTRY BUILDING
BIRMINGHAM AL
35233-2005
US

IV. Provider business mailing address

813 N STILSON RD SUITE C
BOISE ID
83703-5119
US

V. Phone/Fax

Practice location:
  • Phone: 205-934-4551
  • Fax:
Mailing address:
  • Phone: 208-344-0908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5817
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60121655
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD444PE
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: