Healthcare Provider Details

I. General information

NPI: 1073947198
Provider Name (Legal Business Name): HOLLY PUTT RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 W WEST COVINA PKWY
WEST COVINA CA
91790-2946
US

IV. Provider business mailing address

11660 CHURCH ST APT 296
RANCHO CUCAMONGA CA
91730-8934
US

V. Phone/Fax

Practice location:
  • Phone: 626-962-8911
  • Fax:
Mailing address:
  • Phone: 909-240-5288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number27009
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: