Provider Demographics
NPI:1598219032
Name:ARCHAMBAULT, BRENDA (RDH)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:ARCHAMBAULT
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 1:471 CARSON OAKS LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-7159
Mailing Address - Country:US
Mailing Address - Phone:850-503-1943
Mailing Address - Fax:
Practice Address - Street 1:2441 US HIGHWAY 98 W
Practice Address - Street 2:STE 107
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-5385
Practice Address - Country:US
Practice Address - Phone:850-622-2226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-13
Last Update Date:2016-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22387124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist