Provider Demographics
NPI:1043658503
Name:CHRISTOPHER J RODEBAUGH, DDS INC
Entity type:Organization
Organization Name:CHRISTOPHER J RODEBAUGH, DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:RODEBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-645-3110
Mailing Address - Street 1:120 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-9736
Mailing Address - Country:US
Mailing Address - Phone:304-645-3110
Mailing Address - Fax:304-645-3209
Practice Address - Street 1:120 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-9736
Practice Address - Country:US
Practice Address - Phone:304-645-3110
Practice Address - Fax:304-645-3209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV38201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV38100178725Medicaid