Healthcare Provider Details

I. General information

NPI: 1013540848
Provider Name (Legal Business Name): KELSI MARIE HARTWIG DENTAL HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 491 NORTH, YUCCA STREET
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 160
SHIPROCK NM
87420-0160
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6358
  • Fax:
Mailing address:
  • Phone: 505-368-6358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH3681
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: