MEDICARE: MS. AUDREY IRENE HERMAN 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	DH60172854	WA

General Provider Information

NPI Number	:	1821394198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AUDREY IRENE HERMAN RDH

Provider Business Mailing Address
First Line	:	PO BOX 152
Second Line	:
City	:	LONG BEACH
State	:	WA
Zip	:	98631-0152
Country	:	US
Telephone Number	:	360-244-5850
Fax Number	:

Provider Business Practice Location Address
First Line	:	2006 N WASHINGTON ST
Second Line	:
City	:	LONG BEACH
State	:	WA
Zip	:	98631-0152
Country	:	US
Telephone Number	:	360-244-5850
Fax Number	:

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

Provider Enumeration Date	:	02/04/2011
Last Update Date	:	02/04/2011

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