MEDICARE: KANJALIA LATRICE STIDHUM 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	102207	NV

General Provider Information

NPI Number	:	1992430029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KANJALIA LATRICE STIDHUM RDH

Provider Business Mailing Address
First Line	:	317 POINT LOMA AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-7863
Country	:	US
Telephone Number	:	702-806-8222
Fax Number	:

Provider Business Practice Location Address
First Line	:	317 POINT LOMA AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-7863
Country	:	US
Telephone Number	:	702-806-8222
Fax Number	:

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

Provider Enumeration Date	:	07/21/2022
Last Update Date	:	10/26/2023

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