MEDICARE: MISS TERRI FATA RDH

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	2902008635	MI

General Provider Information

NPI Number	:	1205134772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS TERRI FATA RDH

Provider Business Mailing Address
First Line	:	38372 TIMBERLAND DR
Second Line	:
City	:	WESTLAND
State	:	MI
Zip	:	48185-2688
Country	:	US
Telephone Number	:	734-207-6297
Fax Number	:

Provider Business Practice Location Address
First Line	:	559 W GRAND BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48216-2200
Country	:	US
Telephone Number	:	313-554-3880
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2011
Last Update Date	:	03/08/2011

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