Provider Demographics
NPI:1629399423
Name:CHENNAULT, CYNTHIA NICOLE (RDH)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:NICOLE
Last Name:CHENNAULT
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 1:669 AGENCY MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:HARLEM
Mailing Address - State:MT
Mailing Address - Zip Code:59526
Mailing Address - Country:US
Mailing Address - Phone:406-353-3168
Mailing Address - Fax:406-353-3227
Practice Address - Street 1:669 AGENCY MAIN STREET
Practice Address - Street 2:
Practice Address - City:HARLEM
Practice Address - State:MT
Practice Address - Zip Code:59526
Practice Address - Country:US
Practice Address - Phone:406-353-3168
Practice Address - Fax:406-353-3227
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15149124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15149OtherLICENSE