Healthcare Provider Details

I. General information

NPI: 1225244551
Provider Name (Legal Business Name): KIMBERLEY DAWN LEGASPI RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 B STREET
PLUMMER ID
83851-0388
US

IV. Provider business mailing address

4152 N MAGNOLIA DR
COEUR D ALENE ID
83815-9641
US

V. Phone/Fax

Practice location:
  • Phone: 208-686-1931
  • Fax:
Mailing address:
  • Phone: 208-686-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH-0757
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: