Provider Demographics
NPI:1508155623
Name:BEAUDRY, KATHLEEN A (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:BEAUDRY
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 N STILSON RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5119
Mailing Address - Country:US
Mailing Address - Phone:208-344-0908
Mailing Address - Fax:
Practice Address - Street 1:1919 7TH AVE S
Practice Address - Street 2:412 SCHOOL OF DENTISTRY BUILDING
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-2005
Practice Address - Country:US
Practice Address - Phone:205-934-4551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5817122300000X
WADE60121655122300000X
IDD444PE1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist