Healthcare Provider Details

I. General information

NPI: 1558036616
Provider Name (Legal Business Name): LAURA AILEEN ROSENDAUL HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8385 DIVISION RD
WHITE CITY OR
97503-1176
US

IV. Provider business mailing address

1000 E MAIN ST
MEDFORD OR
97504-7667
US

V. Phone/Fax

Practice location:
  • Phone: 541-826-5853
  • Fax: 541-826-5843
Mailing address:
  • Phone: 541-826-5853
  • Fax: 541-826-5843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH4699
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: