Healthcare Provider Details

I. General information

NPI: 1124488077
Provider Name (Legal Business Name): RAUCH FANILY DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 S GROVE ST
RIPON WI
54971-1828
US

IV. Provider business mailing address

929 S GROVE ST
RIPON WI
54971-1828
US

V. Phone/Fax

Practice location:
  • Phone: 920-748-3633
  • Fax:
Mailing address:
  • Phone: 920-748-3633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER J RAUCH
Title or Position: OWNER
Credential: DDS
Phone: 920-748-3633