Provider Demographics
NPI:1336580919
Name:PINE, PATRICIA M (RDH,OM)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:M
Last Name:PINE
Suffix:
Gender:F
Credentials:RDH,OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16422 E CRYSTAL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-8415
Mailing Address - Country:US
Mailing Address - Phone:847-207-7463
Mailing Address - Fax:
Practice Address - Street 1:16422 E CRYSTAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-8415
Practice Address - Country:US
Practice Address - Phone:847-207-7463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH4381124Q00000X
IL020-004876124Q00000X
WI6743-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist