Healthcare Provider Details

I. General information

NPI: 1316608516
Provider Name (Legal Business Name): KACY HUFFMAN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 S LAKE DR APT 4
ST FRANCIS WI
53235-5256
US

IV. Provider business mailing address

4060 S LAKE DR APT 4
ST FRANCIS WI
53235-5256
US

V. Phone/Fax

Practice location:
  • Phone: 407-375-3003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number10392-16
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: