Healthcare Provider Details

I. General information

NPI: 1841704947
Provider Name (Legal Business Name): ROBIN LAINE KELLER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. ROBIN LAINE HOSKINSON

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 WETZEL AVE BLDG 815
FORT CARSON CO
80913-4095
US

IV. Provider business mailing address

1631 WETZEL AVE BLDG 815
FORT CARSON CO
80913-4095
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-5537
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH.000904129
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: