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General NPI Number Information
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NPI Number | 1508155623
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Entity Type | Individual
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Provider Name | KATHLEEN A BEAUDRY D.M.D., M.S.
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Gender | Female
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Dates
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Enumeration Date | 03/29/2011
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Last Update Date | 04/10/2013
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Provider Practice Location Address
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Address Line | 1919 7TH AVE S 412 SCHOOL OF DENTISTRY BUILDING
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City | BIRMINGHAM
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State | AL
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Zip | 35233-2005
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Country | US
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Telephone | 205-934-4551
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Fax |
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Provider Business Mailing Address
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Address Line | 813 N STILSON RD SUITE C
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City | BOISE
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State | ID
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Zip | 83703-5119
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Country | US
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Telephone | 208-344-0908
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5817
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DE60121655
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | D444PE
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License Number State | ID
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