Provider Demographics
NPI:1104278407
Name:VIGOREN, KELLIE (RDH)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:VIGOREN
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 1:7368 S HUDSON WAY
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122-2549
Mailing Address - Country:US
Mailing Address - Phone:505-379-0880
Mailing Address - Fax:
Practice Address - Street 1:7368 S HUDSON WAY
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80122-2549
Practice Address - Country:US
Practice Address - Phone:505-379-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002024458124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist