Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | DH2335 | ID |
NPI | 1053563619 |
---|---|
Provider Name | Kellie Renee Bergendahl |
First Address | Coeur D Alene, ID 83816-0994 |
Second Address | Plummer, ID 83851-4000 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/10/2008 |
Last Update Date | 23/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RDH 20164 | STATE LICENSE (01) | CA |