MEDICARE: DENTAL HYGIENE VISITING SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	2902010375	MI

General Provider Information

NPI Number	:	1053748889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL HYGIENE VISITING SERVICES

Provider Business Mailing Address
First Line	:	38 ADELAIDE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-3111
Country	:	US
Telephone Number	:	313-407-1400
Fax Number	:	313-784-9136

Provider Business Practice Location Address
First Line	:	38 ADELAIDE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-3111
Country	:	US
Telephone Number	:	313-407-1400
Fax Number	:	313-784-9136

Authorized Official
Title or Position	:	OWNER-HYGIENIST
Name	:	MS. LESLIE LORAY MCCLENIC
Credential	:	RDH
Telephone Number	:	313-407-1400

Provider Enumeration Date	:	10/12/2013
Last Update Date	:	10/12/2013

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