Provider Demographics
NPI:1942754577
Name:FLOOD, KATIE SUSAN (RDH, BS)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:SUSAN
Last Name:FLOOD
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 ANTELOPE LOOP
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-5733
Mailing Address - Country:US
Mailing Address - Phone:480-695-2644
Mailing Address - Fax:
Practice Address - Street 1:644 ANTELOPE LOOP
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-5733
Practice Address - Country:US
Practice Address - Phone:480-695-2644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5742124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ12Medicaid