=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134270671
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLEY J. MORAN R.D.H., C.D.H.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8752 S WIND PUDDING DR
-----------------------------------------------------
City | HAZELHURST
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54531-9731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-277-2550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8752 S WIND PUDDING DR
-----------------------------------------------------
City | HAZELHURST
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54531-9731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-277-2550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 5010-016
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------