MEDICARE: BETTY JO HAYNES RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	1694	TX

General Provider Information

NPI Number	:	1295090199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETTY JO HAYNES RDH

Provider Business Mailing Address
First Line	:	12414 MILLRIDGE PINES CT
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-4896
Country	:	US
Telephone Number	:	281-546-2997
Fax Number	:

Provider Business Practice Location Address
First Line	:	12414 MILLRIDGE PINES CT
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-4896
Country	:	US
Telephone Number	:	281-546-2997
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2012
Last Update Date	:	07/07/2012

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