Healthcare Provider Details

I. General information

NPI: 1275235632
Provider Name (Legal Business Name): AUDRA RAUH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 W SPRINGFIELD AVE
CHAMPAIGN IL
61821-3007
US

IV. Provider business mailing address

7703 FLOYD CURL DR
SAN ANTONIO TX
78229-3901
US

V. Phone/Fax

Practice location:
  • Phone: 217-355-6396
  • Fax:
Mailing address:
  • Phone: 806-626-2697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.034680
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: