Healthcare Provider Details

I. General information

NPI: 1891138087
Provider Name (Legal Business Name): KATHERN MARIE TWIDWELL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 04/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S MAIN ST
PIEDMONT MO
63957-1563
US

IV. Provider business mailing address

100 S MAIN ST
PIEDMONT MO
63957-1563
US

V. Phone/Fax

Practice location:
  • Phone: 573-223-4513
  • Fax:
Mailing address:
  • Phone: 573-223-4513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2009015247
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: