Provider Demographics
NPI:1033499249
Name:DORNBUSH, CAROLINE CATHLEEN (RDHAP)
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:CATHLEEN
Last Name:DORNBUSH
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 SWEETWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-2045
Mailing Address - Country:US
Mailing Address - Phone:209-365-0350
Mailing Address - Fax:209-365-0350
Practice Address - Street 1:3020 SWEETWOOD DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-2045
Practice Address - Country:US
Practice Address - Phone:209-365-0350
Practice Address - Fax:209-365-0350
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP86124Q00000X
CARDH8485124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist