Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H5094 | OR |
NPI | 1053784538 |
---|---|
Provider Name | Kimberly Holliday |
First Address | Bend, OR 97701-6068 |
Second Address | Bend, OR 97701-6068 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/11/2015 |
Last Update Date | 05/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
270364023 | (05) | OR |