Provider Demographics
NPI:1518912914
Name:SACHAU, GLEN RANDAL (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:RANDAL
Last Name:SACHAU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:G.
Other - Middle Name:RANDY
Other - Last Name:SACHAU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1440 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-1532
Mailing Address - Country:US
Mailing Address - Phone:605-642-5767
Mailing Address - Fax:605-642-5769
Practice Address - Street 1:1440 N 10TH ST
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1532
Practice Address - Country:US
Practice Address - Phone:605-642-5767
Practice Address - Fax:605-642-5769
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM-5121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice