Provider Demographics
NPI:1184884348
Name:MCRAE DENTAL PA
Entity type:Organization
Organization Name:MCRAE DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:LON
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:MCRAE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-894-8486
Mailing Address - Street 1:1067 S WELLS ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7997
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:83642-3561
Practice Address - Country:US
Practice Address - Phone:208-895-8486
Practice Address - Fax:208-895-8540
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCRAE DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-11
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID000673526W261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805008600Medicaid