Healthcare Provider Details

I. General information

NPI: 1730197310
Provider Name (Legal Business Name): JOETTE MARIE WYMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 CHARLES STREET
BANGOR MI
49013
US

IV. Provider business mailing address

50 INDUSTRIAL PARK DRIVE
BANGOR MI
49013
US

V. Phone/Fax

Practice location:
  • Phone: 269-427-7969
  • Fax: 269-427-9539
Mailing address:
  • Phone: 269-427-7937
  • Fax: 269-427-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902008214
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: