Healthcare Provider Details

I. General information

NPI: 1801235221
Provider Name (Legal Business Name): MICHELLE ANNE LOWERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SAIPAN STREET
SANTA RITA GU
96915
US

IV. Provider business mailing address

5 SAIPAN ST
SANTA RITA GU
96915-1441
US

V. Phone/Fax

Practice location:
  • Phone: 671-564-0886
  • Fax:
Mailing address:
  • Phone: 671-564-0886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number007017
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: