Healthcare Provider Details

I. General information

NPI: 1699818096
Provider Name (Legal Business Name): KITRINA ROXANNE MALLON DENTAL HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 MASSACHUSETTS ST
LAWRENCE KS
66046-4827
US

IV. Provider business mailing address

414 2ND ST
BALDWIN CITY KS
66006-5074
US

V. Phone/Fax

Practice location:
  • Phone: 785-832-4803
  • Fax:
Mailing address:
  • Phone: 785-594-2488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2588
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: