Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 903659 | CO |
NPI | 1003298738 |
---|---|
Provider Name | Kirsten Tacha |
First Address | Colorado Springs, CO 80917-5147 |
Second Address | Limon, CO 80828 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2015 |
Last Update Date | 05/04/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
05622760 | (05) | CO |