MEDICARE: MRS. ELIZABETH M KIDDER D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12736	MN
2	122300000X	Dentist	6020015	WI
3	122300000X	Dentist	6640	LA

General Provider Information

NPI Number	:	1912102070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELIZABETH M KIDDER D.D.S.

Provider Business Mailing Address
First Line	:	6535 PERKINS ROAD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70808
Country	:	US
Telephone Number	:	225-761-8585
Fax Number	:	225-761-1979

Provider Business Practice Location Address
First Line	:	6535 PERKINS ROAD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70808
Country	:	US
Telephone Number	:	225-761-8585
Fax Number	:	225-761-1979

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2007
Last Update Date	:	07/21/2022

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