Healthcare Provider Details

I. General information

NPI: 1669297370
Provider Name (Legal Business Name): MICHELLE A OLVERA YERENA RDH,PHDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 N 8TH ST
PEKIN IL
61554-1547
US

IV. Provider business mailing address

5008 S MORGAN ST
CHICAGO IL
60609-5150
US

V. Phone/Fax

Practice location:
  • Phone: 309-382-6404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: