=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811281397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREA S RADABAUGH DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2011
-----------------------------------------------------
Last Update Date | 06/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 DIVISION AVE
-----------------------------------------------------
City | CRAIGMONT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-924-5830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 218
-----------------------------------------------------
City | CRAIGMONT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83523-0218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-333-7853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | DR. ANDREA S RADABAUGH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 530-333-7853
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D4296
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------