Provider Demographics
NPI:1770834970
Name:MICKELSON, GABRIELLE K (RDH, PHRDH)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:K
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:RDH, PHRDH
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:K
Other - Last Name:HOFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH, PHRDH
Mailing Address - Street 1:204 W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4654
Mailing Address - Country:US
Mailing Address - Phone:308-641-7414
Mailing Address - Fax:
Practice Address - Street 1:204 W 36TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361
Practice Address - Country:US
Practice Address - Phone:308-641-7414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2018-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE174400000X
NE1976124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No174400000XOther Service ProvidersSpecialist