Provider Demographics
NPI:1558000398
Name:RAUDEBAUGH, ADAM (DMD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:RAUDEBAUGH
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 1:180 N ADA ST APT 514
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9443 W 144TH PLACE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2543
Practice Address - Country:US
Practice Address - Phone:708-403-9848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL319.0232191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL319.023219OtherDENTAL LICENSE