Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | DH-3679 | ID |
N | 124Q00000X | Dental Hygienist | DH60888742 | WA |
NPI | 1073095501 |
---|---|
Provider Name | Carmen Lee Koepl |
First Address | Spokane, WA 99202-4932 |
Second Address | Moscow, ID 83843-2695 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2018 |
Last Update Date | 31/03/2021 |