Active NPI
Lyle Thomas Roudabush, D.D.S.
- General Practice Dentistry
- Grinnell, IA
National Provider Identifier
1861520652
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 5719
- Practice address
- 825 Broad St
Grinnell, IA 50112-2153 - Phone
- (641) 236-6169
- Fax
- (641) 236-6041
- NPI assigned
- Mar 1, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 5719 | IA | Primary |
Addresses
Primary practice location
825 Broad St
Grinnell, IA 50112-2153
Mailing address
125 16TH Ave.
Grinnell, IA 50112
Phone (641) 236-8139
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5719 | IA | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Family Dentistry, LLP | General Practice | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1172707200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1861520652",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "125 16TH AVE.",
"city": "GRINNELL",
"state": "IA",
"postal_code": "50112",
"telephone_number": "641-236-8139",
"fax_number": "641-236-6041"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "825 BROAD ST",
"city": "GRINNELL",
"state": "IA",
"postal_code": "501122153",
"telephone_number": "641-236-6169",
"fax_number": "641-236-6041"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROUDABUSH",
"first_name": "LYLE",
"middle_name": "THOMAS",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-03-01",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "IA",
"license": "5719",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Grinnell, IA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.