Healthcare Provider Details

I. General information

NPI: 1629399423
Provider Name (Legal Business Name): CYNTHIA NICOLE CHENNAULT RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 AGENCY MAIN STREET
HARLEM MT
59526
US

IV. Provider business mailing address

669 AGENCY MAIN STREET
HARLEM MT
59526
US

V. Phone/Fax

Practice location:
  • Phone: 406-353-3168
  • Fax: 406-353-3227
Mailing address:
  • Phone: 406-353-3168
  • Fax: 406-353-3227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number15149
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: