Basic Information
| Provider Information | |||||||||
| NPI: | 1114059722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | CONSTANCE | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | HYGIENIST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STEWART | ||||||||
| OtherFirstName: | CONSTANCE | ||||||||
| OtherMiddleName: | SUZANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | HYGIENIST | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2960 TONGASS AVE | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072284902 | ||||||||
| FaxNumber: | 9072285256 | ||||||||
| Practice Location | |||||||||
| Address1: | 2960 TONGASS AVE | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072284902 | ||||||||
| FaxNumber: | 9072285256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 493 | AK | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 493 | 01 | AK | DENTAL HYGIENE LICENSE | OTHER | 174 | 01 | AK | HYGIENIST LICENSED TO ADM | OTHER |