Basic Information
| Provider Information | |||||||||
| NPI: | 1396318713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLEAZARD | ||||||||
| FirstName: | RACHAEL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 E COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993441846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094885256 | ||||||||
| FaxNumber: | 5094889939 | ||||||||
| Practice Location | |||||||||
| Address1: | 1051 COLUMBIA AVE | ||||||||
| Address2: | |||||||||
| City: | CONNELL | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993268702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094885256 | ||||||||
| FaxNumber: | 5094889939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2021 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH60684821 | WA | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | DH60684821 | 01 | WA | DOH LICENSE | OTHER |