Provider Demographics
NPI:1083216055
Name:HILLER, MARY (RDH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:HILLER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 TUTT BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-2515
Mailing Address - Country:US
Mailing Address - Phone:719-380-0141
Mailing Address - Fax:
Practice Address - Street 1:5430 TUTT BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2515
Practice Address - Country:US
Practice Address - Phone:719-380-0141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002023800124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO002023800OtherRDH