Provider Demographics
NPI:1013506591
Name:ELEVATE DENTAL HYGIENE LLC
Entity Type:Organization
Organization Name:ELEVATE DENTAL HYGIENE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:208-731-8723
Mailing Address - Street 1:721 NORTHSTAR DR
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-8501
Mailing Address - Country:US
Mailing Address - Phone:208-731-8723
Mailing Address - Fax:
Practice Address - Street 1:630 SUN VALLEY ROAD SUITE D102
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-731-8723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1851496137OtherNPPES
ID1649898578OtherNPPES