Healthcare Provider Details

I. General information

NPI: 1811158850
Provider Name (Legal Business Name): BRENDA R LAW RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 N KENTUCKY AVE
MADISONVILLE KY
42431-1711
US

IV. Provider business mailing address

412 N KENTUCKY AVE
MADISONVILLE KY
42431-1711
US

V. Phone/Fax

Practice location:
  • Phone: 270-821-5242
  • Fax: 270-825-0138
Mailing address:
  • Phone: 270-821-5242
  • Fax: 270-825-0138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2170
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: