Healthcare Provider Details

I. General information

NPI: 1629036793
Provider Name (Legal Business Name): BRENDA MARIE RAU RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 KANAKANAK RD
DILLINGHAM AK
99576
US

IV. Provider business mailing address

PO BOX 1286
DILLINGHAM AK
99576
US

V. Phone/Fax

Practice location:
  • Phone: 907-842-5201
  • Fax: 907-842-9250
Mailing address:
  • Phone: 907-842-5231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: