Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2023953 | CO |
NPI | 1053716308 |
---|---|
Provider Name | Michele Rewerts |
First Address | Evans, CO 80620-1011 |
Second Address | Loveland, CO 80537-6419 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/10/2014 |
Last Update Date | 10/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
75750341 | (05) | CO |