Provider Demographics
NPI:1992430029
Name:STIDHUM, KANJALIA LATRICE (RDH)
Entity type:Individual
Prefix:
First Name:KANJALIA
Middle Name:LATRICE
Last Name:STIDHUM
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 POINT LOMA AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-7863
Mailing Address - Country:US
Mailing Address - Phone:702-806-8222
Mailing Address - Fax:
Practice Address - Street 1:317 POINT LOMA AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-7863
Practice Address - Country:US
Practice Address - Phone:702-806-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV102207124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty