=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902983224
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HARRY RADDIN JR. D.D.S.,M.S.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 01/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13841 HULL STREET RD SUITE 4
-----------------------------------------------------
City | MIDLOTHIAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23112-2056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-739-0963
-----------------------------------------------------
Fax | 804-739-0965
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13841 HULL STREET RD SUITE 4
-----------------------------------------------------
City | MIDLOTHIAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23112-2056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-739-0963
-----------------------------------------------------
Fax | 804-739-0965
-----------------------------------------------------
=====================================================
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 | 0401004475
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------