Provider Demographics
NPI:1306940317
Name:LIDRAL, ANDREW CARL (DDS PHD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:CARL
Last Name:LIDRAL
Suffix:
Gender:M
Credentials:DDS PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 MARCELL DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341
Mailing Address - Country:US
Mailing Address - Phone:616-866-8010
Mailing Address - Fax:616-866-7401
Practice Address - Street 1:158 MARCELL DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341
Practice Address - Country:US
Practice Address - Phone:616-866-8010
Practice Address - Fax:616-866-7401
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA075391223X0400X
MI214471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0250654Medicaid