Basic Information
| Provider Information | |||||||||
| NPI: | 1538746458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | KERRI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1534 PATRIOT DR | ||||||||
| Address2: | |||||||||
| City: | JUNCTION CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664411984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503776369 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4010 1ST DIVISION RD | ||||||||
| Address2: | |||||||||
| City: | FT RILEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852394174 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2021 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH24313 | FL | Y | Dental Providers | Dental Hygienist |
No ID Information.