1184030686 NPI number — DR. ANDREW THOMAS CHADBOURN DMD

Table of content: DR. ANDREW THOMAS CHADBOURN DMD (NPI 1184030686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184030686 NPI number — DR. ANDREW THOMAS CHADBOURN DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHADBOURN
Provider First Name:
ANDREW
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184030686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9120 BALTIMORE ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAINE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55449-4337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-786-1560
Provider Business Mailing Address Fax Number:
763-786-4390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9120 BALTIMORE ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLAINE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55449-4337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-786-1560
Provider Business Practice Location Address Fax Number:
763-786-4390
Provider Enumeration Date:
07/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D13439 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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