=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568147692
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUIZA KIYAMOVA RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2023
-----------------------------------------------------
Last Update Date | 06/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 606 OLD ROUTE 17
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12701-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-707-8483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 SHORTCUT RD
-----------------------------------------------------
City | COCHECTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12726-5316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-705-2146
-----------------------------------------------------
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 | 030692
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------