Healthcare Provider Details

I. General information

NPI: 1669190831
Provider Name (Legal Business Name): KRISSI CLYMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 08/15/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KANEOHE BAY DRIVE
KAILUA HI
96734
US

IV. Provider business mailing address

1607 PUHI LN
KAILUA HI
96734-4992
US

V. Phone/Fax

Practice location:
  • Phone: 314-727-4100
  • Fax:
Mailing address:
  • Phone: 303-856-5385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH.002025609
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2245
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number31.015642
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: