Healthcare Provider Details

I. General information

NPI: 1053563619
Provider Name (Legal Business Name): KELLIE RENEE BERGENDAHL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE R. MCNEIL RDH

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 12TH ST
PLUMMER ID
83851-4000
US

IV. Provider business mailing address

PO BOX 994
COEUR D ALENE ID
83816-0994
US

V. Phone/Fax

Practice location:
  • Phone: 208-686-1931
  • Fax: 208-686-5133
Mailing address:
  • Phone: 208-625-0353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH2335
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: