Provider Demographics
NPI:1558438903
Name:MCRAE, LON CHAD (DMD)
Entity Type:Individual
Prefix:
First Name:LON
Middle Name:CHAD
Last Name:MCRAE
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 1:1067 S. WELLS ST.
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-895-8486
Mailing Address - Fax:208-895-8540
Practice Address - Street 1:1067 S WELLS ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7997
Practice Address - Country:US
Practice Address - Phone:208-895-8486
Practice Address - Fax:208-895-8540
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3214122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805008600Medicaid