Healthcare Provider Details

I. General information

NPI: 1194101568
Provider Name (Legal Business Name): LYDIA MCCOY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2990 MILITARY AVE
BAXTER SPRINGS KS
66713-2331
US

IV. Provider business mailing address

PO BOX 1832
PITTSBURG KS
66762-1832
US

V. Phone/Fax

Practice location:
  • Phone: 620-856-2900
  • Fax: 620-856-2901
Mailing address:
  • Phone: 888-777-9170
  • Fax: 620-231-5062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number102022
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: