Provider Demographics
NPI:1720506660
Name:KLINE, CAROL SUE (RDH)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:SUE
Last Name:KLINE
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 1:1733 RED SAGE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-1535
Mailing Address - Country:US
Mailing Address - Phone:518-572-4710
Mailing Address - Fax:
Practice Address - Street 1:1835 XIMENO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-2850
Practice Address - Country:US
Practice Address - Phone:562-453-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31043124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA31043Medicaid