Provider Demographics
NPI:1710359856
Name:POOLE, KATHERYN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHERYN
Middle Name:
Last Name:POOLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2852
Mailing Address - Street 2:41628 BIG BEAR BLVD
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315-2852
Mailing Address - Country:US
Mailing Address - Phone:909-866-2848
Mailing Address - Fax:909-866-1796
Practice Address - Street 1:41628 BIG BEAR BLVD.
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315
Practice Address - Country:US
Practice Address - Phone:909-866-2646
Practice Address - Fax:909-866-1796
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40110122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist