=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740057447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA NICOLE WOOLAM DH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2023
-----------------------------------------------------
Last Update Date | 12/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4575 BYRD DR
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-7198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-593-3300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4195 LOST CANYON DR
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-8771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-500-2418
-----------------------------------------------------
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 | 002026784
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------