Healthcare Provider Details

I. General information

NPI: 1003037672
Provider Name (Legal Business Name): KATHERINE CLENDENIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6729 BRIDGE ST
FT WORTH TX
76112
US

IV. Provider business mailing address

6729 BRIDGE ST
FT WORTH TX
76112
US

V. Phone/Fax

Practice location:
  • Phone: 817-654-0354
  • Fax:
Mailing address:
  • Phone: 817-654-0354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number10092
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: