=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518179258
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA JANE BROTHERS RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 NORTH MAIN STREET
-----------------------------------------------------
City | GUNNISON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-641-5363
-----------------------------------------------------
Fax | 970-641-5364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 WILD RIVER LANE
-----------------------------------------------------
City | GUNNISON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-642-0338
-----------------------------------------------------
Fax | 970-641-5364
-----------------------------------------------------
=====================================================
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 | 904700
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------