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NPI Code Detail

MEDICARE: ALICIA NICOLE GENDRON RDH

MEDICARE: ALICIA NICOLE GENDRON 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
1124Q00000XDental Hygienist1003347-16WI

General Provider Information

NPI Number : 1467934851
Entity Type Code : Individual
Provider Name (Legal Business Name) : ALICIA NICOLE GENDRON RDH
Provider Business Mailing Address
First Line : 350 S PECK AVE
Second Line :
City : PESHTIGO
State : WI
Zip : 54157-1511
Country : US
Telephone Number : 906-285-3545
Fax Number :
Provider Business Practice Location Address
First Line : 2280 W MASON ST
Second Line :
City : GREEN BAY
State : WI
Zip : 54303-4707
Country : US
Telephone Number : 920-321-3501
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/31/2018
Last Update Date : 08/31/2018

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Directions to “ ALICIA NICOLE GENDRON RDH” Practice Location

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