MEDICARE: MRS. MARIE KONOSKE R.D.H.

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	2902010252	MI

General Provider Information

NPI Number	:	1568430114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIE KONOSKE R.D.H.

Provider Business Mailing Address
First Line	:	187 DEMBOSKI RD
Second Line	:
City	:	IRON RIVER
State	:	MI
Zip	:	49935-8512
Country	:	US
Telephone Number	:	906-265-3416
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 S 4TH ST
Second Line	:
City	:	CRYSTAL FALLS
State	:	MI
Zip	:	49920-1503
Country	:	US
Telephone Number	:	906-875-6133
Fax Number	:

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

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	07/08/2007

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