Healthcare Provider Details

I. General information

NPI: 1861562738
Provider Name (Legal Business Name): MARY ELIZABETH TIMOTHY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95TH MEDICAL GROUP SGDH 30 NIGHTINGALE RD
EDWARDS AFB CA
93524-1760
US

IV. Provider business mailing address

9137 HOLLY AVE
CALIFORNIA CITY CA
93505-2806
US

V. Phone/Fax

Practice location:
  • Phone: 661-277-2872
  • Fax: 661-277-4728
Mailing address:
  • Phone: 760-373-2049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number20888
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: