Basic Information
| Provider Information | |||||||||
| NPI: | 1831581024 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIDS DENTAL HYGIENE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4040 | ||||||||
| Address2: | |||||||||
| City: | BUENA VISTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812114040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193959048 | ||||||||
| FaxNumber: | 7193959064 | ||||||||
| Practice Location | |||||||||
| Address1: | 28374 COUNTY ROAD 317 | ||||||||
| Address2: | |||||||||
| City: | BUENA VISTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812119158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193959048 | ||||||||
| FaxNumber: | 7193959064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2015 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BORIA | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTAL HYGIENIST | ||||||||
| AuthorizedOfficialTelephone: | 7192215273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RDH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH000201412 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dental Hygienist |
No ID Information.