Provider Demographics
NPI:1659591378
Name:HOUSEHOLDER, LORENE
Entity Type:Individual
Prefix:
First Name:LORENE
Middle Name:
Last Name:HOUSEHOLDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 SIDEWINDER DR
Mailing Address - Street 2:STE 102
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7322
Mailing Address - Country:US
Mailing Address - Phone:435-649-9492
Mailing Address - Fax:
Practice Address - Street 1:1729 SIDEWINDER DR
Practice Address - Street 2:STE 102
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7322
Practice Address - Country:US
Practice Address - Phone:435-649-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT378375-0701124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist