Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 12818 | KS |
NPI | 1043882335 |
---|---|
Provider Name | Heather Tedlock |
First Address | Pittsburg, KS 66762-1832 |
Second Address | Pittsburg, KS 66762-2546 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2021 |
Last Update Date | 15/07/2021 |