Healthcare Provider Details

I. General information

NPI: 1811681042
Provider Name (Legal Business Name): DIVINE DENTAL HYGIENE PRACTICE OF AMANDA SOLIS, RDHAP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9412 MIDWAY
DURHAM CA
95938-9535
US

IV. Provider business mailing address

PO BOX 1132
DURHAM CA
95938-1132
US

V. Phone/Fax

Practice location:
  • Phone: 530-399-0103
  • Fax:
Mailing address:
  • Phone: 530-399-0103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: AMANDA T SOLIS
Title or Position: PRESIDENT
Credential:
Phone: 530-399-0103