Healthcare Provider Details

I. General information

NPI: 1154639151
Provider Name (Legal Business Name): KATYA BRIANNA KANUK D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 09/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RAF LAKENHEATH 48 MDG/SGHC BLDG 922, ROOM 220
BRANDON SUFFOLK
IP28 9PN
GB

IV. Provider business mailing address

RAF LAKENHEATH 48 MDG/SGHC BLDG 922, ROOM 220
BRANDON SUFFOLK
IP28 9PN
GB

V. Phone/Fax

Practice location:
  • Phone: 011441638528124
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number25078
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: