Provider Demographics
NPI:1184030686
Name:CHADBOURN, ANDREW THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:THOMAS
Last Name:CHADBOURN
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 1:9120 BALTIMORE ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4337
Mailing Address - Country:US
Mailing Address - Phone:763-786-1560
Mailing Address - Fax:763-786-4390
Practice Address - Street 1:9120 BALTIMORE ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4337
Practice Address - Country:US
Practice Address - Phone:763-786-1560
Practice Address - Fax:763-786-4390
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13439122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist