Provider Demographics
NPI:1780433995
Name:BAILEY, KADERUS (DDS)
Entity type:Individual
Prefix:DR
First Name:KADERUS
Middle Name:
Last Name:BAILEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 MANCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1142
Mailing Address - Country:US
Mailing Address - Phone:704-390-0868
Mailing Address - Fax:
Practice Address - Street 1:2000 OPELOUSAS ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-2641
Practice Address - Country:US
Practice Address - Phone:337-439-9983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7608122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes122300000XDental ProvidersDentist