Healthcare Provider Details

I. General information

NPI: 1730670639
Provider Name (Legal Business Name): KATHLEEN MCMANNES LDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4629 MELTON RD
GARY IN
46403-2866
US

IV. Provider business mailing address

1267 W 95TH PL
CROWN POINT IN
46307-2276
US

V. Phone/Fax

Practice location:
  • Phone: 219-938-2637
  • Fax:
Mailing address:
  • Phone: 219-628-5295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number13007475A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: