Provider Demographics
NPI:1093969107
Name:BLOME, RENAE DAWN (RDH)
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:DAWN
Last Name:BLOME
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4366 270TH ST E
Mailing Address - Street 2:PO BOX 237
Mailing Address - City:MEDFORD
Mailing Address - State:MN
Mailing Address - Zip Code:55049-8001
Mailing Address - Country:US
Mailing Address - Phone:507-475-0628
Mailing Address - Fax:507-446-1098
Practice Address - Street 1:4366 270TH ST E
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MN
Practice Address - Zip Code:55049-8001
Practice Address - Country:US
Practice Address - Phone:507-475-0628
Practice Address - Fax:507-446-1098
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH6616124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist