Basic Information
| Provider Information | |||||||||
| NPI: | 1164898532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAUDERBACK | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9900 LINCOLN STREET, 2ND FLOOR | ||||||||
| Address2: | ATTN: CREDENTIALS OFFICE | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684079 | ||||||||
| FaxNumber: | 2539685916 | ||||||||
| Practice Location | |||||||||
| Address1: | 9900 LINCOLN STREET, 2ND FLOOR | ||||||||
| Address2: | ATTN: CREDENTIALS OFFICE | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684079 | ||||||||
| FaxNumber: | 2539685916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2015 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS0000010113 | TN | Y | Dental Providers | Dentist |
No ID Information.