Provider Demographics
NPI:1174110803
Name:RALEY, JANNELLE LYNN (RDH)
Entity type:Individual
Prefix:
First Name:JANNELLE
Middle Name:LYNN
Last Name:RALEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JANNELLE
Other - Middle Name:LYNN
Other - Last Name:RALEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DH
Mailing Address - Street 1:6636 W 95TH PL
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-6425
Mailing Address - Country:US
Mailing Address - Phone:303-667-9337
Mailing Address - Fax:
Practice Address - Street 1:12889 QUEBEC ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80602-9623
Practice Address - Country:US
Practice Address - Phone:720-726-6830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.000905694124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODH.000905694OtherPRIVEN INS