Provider Demographics
NPI:1518206143
Name:DE VRIES, DEBORAH KAY (RDHAP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:KAY
Last Name:DE VRIES
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:KAY
Other - Last Name:DE VRIES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:9428 KENSINGTON CT
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-8543
Mailing Address - Country:US
Mailing Address - Phone:707-479-5611
Mailing Address - Fax:707-837-0441
Practice Address - Street 1:9428 KENSINGTON CT
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-8543
Practice Address - Country:US
Practice Address - Phone:707-479-5611
Practice Address - Fax:707-837-0441
Is Sole Proprietor?:No
Enumeration Date:2013-02-01
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24727124Q00000X
CAHAP482124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366688418Medicaid