Provider Demographics
NPI:1982074142
Name:SERENE DENTAL HYGIENE
Entity Type:Organization
Organization Name:SERENE DENTAL HYGIENE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:KINZER
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:719-290-9804
Mailing Address - Street 1:8120 ENGLETON CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-6150
Mailing Address - Country:US
Mailing Address - Phone:719-290-9804
Mailing Address - Fax:
Practice Address - Street 1:7770 N UNION BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-4087
Practice Address - Country:US
Practice Address - Phone:719-290-9804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH000902947305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1245606268Medicaid