=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801247242
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUSTIN LEDINGHAM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2016
-----------------------------------------------------
Last Update Date | 06/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 152 S 32ND ST W SUITE A
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59102-6875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-245-4414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2605 CALUMET ST APT 33
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77004-7594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-367-0890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DEN-DEN-LIC-11481
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------