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General NPI Number Information
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NPI Number | 1124676515
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Entity Type | Individual
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Provider Name | TRINA SIMONSON RDH
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Gender | Female
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Dates
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Enumeration Date | 08/28/2019
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Last Update Date | 10/08/2021
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Provider Practice Location Address
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Address Line | 964 COUNTY ROAD T
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City | MARSHALL
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State | WI
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Zip | 53559-9735
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Country | US
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Telephone | 608-988-6472
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Fax |
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Provider Business Mailing Address
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Address Line | W10587 COUNTY ROAD O
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City | PORTAGE
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State | WI
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Zip | 53901-9480
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Country | US
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Telephone | 608-988-6472
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 11590
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License Number State | WI
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