Provider Demographics
NPI:1811281397
Name:ANDREA S RADABAUGH DDS PLLC
Entity type:Organization
Organization Name:ANDREA S RADABAUGH DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:S
Authorized Official - Last Name:RADABAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-333-7853
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:CRAIGMONT
Mailing Address - State:ID
Mailing Address - Zip Code:83523-0218
Mailing Address - Country:US
Mailing Address - Phone:530-333-7853
Mailing Address - Fax:
Practice Address - Street 1:420 DIVISION AVE
Practice Address - Street 2:
Practice Address - City:CRAIGMONT
Practice Address - State:ID
Practice Address - Zip Code:83523
Practice Address - Country:US
Practice Address - Phone:208-924-5830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4296122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty