Provider Demographics
NPI:1356733992
Name:POOLE, KATHLEEN (DDS)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:POOLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:CROWNPOINT
Mailing Address - State:NM
Mailing Address - Zip Code:87313-0358
Mailing Address - Country:US
Mailing Address - Phone:505-786-6283
Mailing Address - Fax:
Practice Address - Street 1:6524 W INDIAN SCHOOL RD STE A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-3329
Practice Address - Country:US
Practice Address - Phone:623-428-2400
Practice Address - Fax:623-777-4120
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2019-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10115122300000X
WV4178122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist