MEDICARE: DOLORES DIANE PRINCE HYGIENIST

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	4517-16	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841445699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOLORES DIANE PRINCE HYGIENIST

Provider Business Mailing Address
First Line	:	2405 NORTHWESTERN AVE
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53404-2534
Country	:	US
Telephone Number	:	262-886-0474
Fax Number	:	262-886-1672

Provider Business Practice Location Address
First Line	:	2405 NORTHWESTERN AVE
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53404-2534
Country	:	US
Telephone Number	:	262-886-0474
Fax Number	:	262-886-1672

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

Provider Enumeration Date	:	11/20/2008
Last Update Date	:	11/20/2008

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