Healthcare Provider Details

I. General information

NPI: 1194326900
Provider Name (Legal Business Name): KASSIDEE N FICKEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/06/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6671 HIGHWAY 36
JOES CO
80822
US

IV. Provider business mailing address

7525 COUNTY ROAD M
KIRK CO
80824-9759
US

V. Phone/Fax

Practice location:
  • Phone: 970-630-4226
  • Fax:
Mailing address:
  • Phone: 970-630-4226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number906449
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: