Holly Ann Daverin, RDH

Key facts

NPI

1245501808

Entity type

Individual (NPI type 1)

Primary specialty

Dental Hygienist 124Q00000X

License

H6127 (OR)

Practice address

29 Black Coal Drive
Fort Washakie Dental Clinic
Fort Washakie, WY 82514-0128

Phone

(307) 332-7300

NPI assigned

Jan 13, 2012

Sex

Female

Sole proprietor

Yes

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

State licenses

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jan 13, 2012.

{
    "created_epoch": "1326412800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1326412800000",
    "number": "1245501808",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11102 W 4000N RD",
            "city": "BONFIELD",
            "state": "IL",
            "postal_code": "609137171",
            "telephone_number": "815-922-7682"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "29 BLACK COAL DRIVE",
            "address_2": "FORT WASHAKIE DENTAL CLINIC",
            "city": "FORT WASHAKIE",
            "state": "WY",
            "postal_code": "825140128",
            "telephone_number": "307-332-7300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DAVERIN",
        "first_name": "HOLLY",
        "middle_name": "ANN",
        "name_prefix": "Ms.",
        "credential": "RDH",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2012-01-13",
        "last_updated": "2012-01-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "124Q00000X",
            "taxonomy_group": "",
            "desc": "Dental Hygienist",
            "state": "OR",
            "license": "H6127",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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