Provider Demographics
NPI:1740391515
Name:RAUCKHORST, ALAN JAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:JAY
Last Name:RAUCKHORST
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 SW HIGGINS AVE STE P
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1430
Mailing Address - Country:US
Mailing Address - Phone:406-251-5709
Mailing Address - Fax:
Practice Address - Street 1:619 SW HIGGINS AVE STE P
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1430
Practice Address - Country:US
Practice Address - Phone:406-251-5709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT19781223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics