Healthcare Provider Details

I. General information

NPI: 1548494420
Provider Name (Legal Business Name): ABBY R DOUGLAS DENTAL HYGIENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ABBY R KOMPROOD

II. Dates (important events)

Enumeration Date: 05/07/2009
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 MAIN ST
DARLINGTON WI
53530-1427
US

IV. Provider business mailing address

74 ECLIPSE CTR
BELOIT WI
53511-3550
US

V. Phone/Fax

Practice location:
  • Phone: 608-776-2082
  • Fax:
Mailing address:
  • Phone: 608-361-0311
  • Fax: 608-361-0312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number6596-016
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: