Provider Demographics
NPI:1174160600
Name:VIRGIN, KATRINA (RDH, MS)
Entity type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:
Last Name:VIRGIN
Suffix:
Gender:F
Credentials:RDH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 BEAVER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6683
Mailing Address - Country:US
Mailing Address - Phone:907-671-3451
Mailing Address - Fax:
Practice Address - Street 1:427 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1528
Practice Address - Country:US
Practice Address - Phone:210-951-3280
Practice Address - Fax:210-858-9220
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK118822124Q00000X
CA23476124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist