Healthcare Provider Details

I. General information

NPI: 1992008213
Provider Name (Legal Business Name): KELLY G. POTTORF HYGIENST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 BIDDLE ST
SAINT LOUIS MO
63106-3454
US

IV. Provider business mailing address

1717 BIDDLE
ST. LOUIS MO
63107
US

V. Phone/Fax

Practice location:
  • Phone: 314-898-1717
  • Fax: 314-814-8542
Mailing address:
  • Phone: 314-898-1717
  • Fax: 314-814-8542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2009007073
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: