Provider Demographics
NPI:1790111250
Name:MISKOVICH, TAMMY KAYE (RDH, CDHC, ED)
Entity Type:Individual
Prefix:MISS
First Name:TAMMY
Middle Name:KAYE
Last Name:MISKOVICH
Suffix:
Gender:F
Credentials:RDH, CDHC, ED
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:KAYE
Other - Last Name:MISKOVICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDA/RDH
Mailing Address - Street 1:PO BOX 851
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55801-0851
Mailing Address - Country:US
Mailing Address - Phone:218-969-9886
Mailing Address - Fax:
Practice Address - Street 1:3614 MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2541
Practice Address - Country:US
Practice Address - Phone:218-969-9886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH5343124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist