Provider Demographics
NPI:1699818096
Name:MALLON, KITRINA ROXANNE (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:
First Name:KITRINA
Middle Name:ROXANNE
Last Name:MALLON
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66006-5074
Mailing Address - Country:US
Mailing Address - Phone:785-594-2488
Mailing Address - Fax:
Practice Address - Street 1:2415 MASSACHUSETTS ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66046-4827
Practice Address - Country:US
Practice Address - Phone:785-832-4803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2588124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist