=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740911643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE FRIENDLY FLOSSER DENTAL HYGIENE PRACTICE OF JENNIFER NOWOTNEY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2022
-----------------------------------------------------
Last Update Date | 06/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11799 SEBASTIAN WAY STE 103
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-0708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-900-8880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12647 TRILLIUM CT
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91739-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-268-7922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/HYGIENIST
-----------------------------------------------------
Name | JENNIFER NOWOTNEY
-----------------------------------------------------
Credential | RDHAP
-----------------------------------------------------
Telephone | 909-900-8880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------