Provider Demographics
NPI:1548576879
Name:RADER, JUSTIN PERRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:PERRY
Last Name:RADER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3250
Mailing Address - Country:US
Mailing Address - Phone:208-664-9225
Mailing Address - Fax:208-667-3699
Practice Address - Street 1:1223 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3250
Practice Address - Country:US
Practice Address - Phone:208-664-9225
Practice Address - Fax:208-667-3699
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4317122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist