Healthcare Provider Details

I. General information

NPI: 1295205169
Provider Name (Legal Business Name): KAYLA RENEE EGGENBERGER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLA RENEE JANSEN RDH

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 S CLEAR CREEK RD #213
FORT HOOD TX
76544
US

IV. Provider business mailing address

606 STATE SCHOOL RD
GATESVILLE TX
76528-2927
US

V. Phone/Fax

Practice location:
  • Phone: 254-285-2014
  • Fax:
Mailing address:
  • Phone: 719-640-2786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number21540
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: