Healthcare Provider Details

I. General information

NPI: 1578834792
Provider Name (Legal Business Name): CORLISS KELLY HALES RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CORLISS KELLY PUTIGNANO RDH

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15182 N. 75TH AVE
PEORIA AZ
85381
US

IV. Provider business mailing address

15182 N. 75TH AVE.
PEORIA AZ
85381
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-2400
  • Fax:
Mailing address:
  • Phone: 623-878-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH6119
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH3927
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: