Healthcare Provider Details

I. General information

NPI: 1215077458
Provider Name (Legal Business Name): DEBRA ANN KOLDEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1599 J ST BLDG 109
GRAND FORKS AFB ND
58205-6306
US

IV. Provider business mailing address

815 DUKE DR APT 236
GRAND FORKS ND
58201-3987
US

V. Phone/Fax

Practice location:
  • Phone: 701-747-5393
  • Fax:
Mailing address:
  • Phone: 701-330-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH7364
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: