Healthcare Provider Details

I. General information

NPI: 1114384393
Provider Name (Legal Business Name): LAUREN YASUDA RAINEY, DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2016
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2519 ASHBY AVE
BERKELEY CA
94705-2205
US

IV. Provider business mailing address

2519 ASHBY AVE
BERKELEY CA
94705-2205
US

V. Phone/Fax

Practice location:
  • Phone: 510-845-7003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number62337
License Number StateCA

VIII. Authorized Official

Name: LAUREN YASUDA RAINEY
Title or Position: DDS
Credential: DDS
Phone: 510-845-7003