Provider Demographics
NPI:1053563619
Name:BERGENDAHL, KELLIE RENEE (RDH)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:RENEE
Last Name:BERGENDAHL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:KELLIE
Other - Middle Name:R
Other - Last Name:MCNEIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDH
Mailing Address - Street 1:PO BOX 994
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-0994
Mailing Address - Country:US
Mailing Address - Phone:208-625-0353
Mailing Address - Fax:
Practice Address - Street 1:427 12TH ST
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851-4000
Practice Address - Country:US
Practice Address - Phone:208-686-1931
Practice Address - Fax:208-686-5133
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDH2335124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDH 20164OtherSTATE LICENSE