Provider Demographics
NPI:1639545429
Name:WHITCOMB, KELLIE (RDH)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:WHITCOMB
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 1:2505 NW ALPINE CREST WAY
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5490
Mailing Address - Country:US
Mailing Address - Phone:206-818-1418
Mailing Address - Fax:425-395-7414
Practice Address - Street 1:2505 NW ALPINE CREST WAY
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5490
Practice Address - Country:US
Practice Address - Phone:206-818-1418
Practice Address - Fax:425-395-7414
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60082963124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist