Provider Demographics
NPI:1083827083
Name:BAILEY, RICHARD E (DMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:BAILEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 QUAIL RUN DR
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-8205
Mailing Address - Country:US
Mailing Address - Phone:208-336-8478
Mailing Address - Fax:
Practice Address - Street 1:301 QUAIL RUN DR
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-8205
Practice Address - Country:US
Practice Address - Phone:509-336-8478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-32561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806766401Medicaid