Basic Information
Provider Information
NPI: 1992321087
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CARDOSO
FirstName: ANDRE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3815 AVENUE F
Address2:  
City: BILLINGS
State: MT
PostalCode: 591027546
CountryCode: US
TelephoneNumber: 8014713690
FaxNumber:  
Practice Location
Address1: 837 N CENTER AVE
Address2:  
City: HARDIN
State: MT
PostalCode: 590341315
CountryCode: US
TelephoneNumber: 4066653300
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/24/2020
LastUpdateDate: 01/07/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 01/07/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X21377MTY Dental ProvidersDentistGeneral Practice

No ID Information.


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