=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174832141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY VERNON CLINE RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2010
-----------------------------------------------------
Last Update Date | 09/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 197 WILDFLOWER RD
-----------------------------------------------------
City | BLANCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78606-1477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-833-5770
-----------------------------------------------------
Fax | 830-833-5075
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1477
-----------------------------------------------------
City | BLANCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78606-1477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-833-5770
-----------------------------------------------------
Fax | 830-833-5075
-----------------------------------------------------
=====================================================
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 | 10773
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------