Healthcare Provider Details

I. General information

NPI: 1194277509
Provider Name (Legal Business Name): SANDRA ENTRY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 ROCK QUARRY RD
RALEIGH NC
27610-3825
US

IV. Provider business mailing address

1001 ROCK QUARRY RD
RALEIGH NC
27610-3825
US

V. Phone/Fax

Practice location:
  • Phone: 919-833-3111
  • Fax: 919-834-3118
Mailing address:
  • Phone: 919-833-3111
  • Fax: 919-834-3118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number11464
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: