Individual
KELLIE RENEE BERGENDAHL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RDH
Contact information
Practice address
427 12TH ST, PLUMMER, ID 83851-4000
(208) 686-1931
(208) 686-5133
Mailing address
PO BOX 994, COEUR D ALENE, ID 83816-0994
(208) 625-0353
Taxonomy
Speciality
Code
Description
License number
State
124Q00000X
Dental Hygienist
Primary
DH2335
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
RDH 20164
STATE LICENSE
CA
Enumeration date
10/15/2008
Last updated
09/23/2019
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