Healthcare Provider Details

I. General information

NPI: 1114010063
Provider Name (Legal Business Name): MS. MARY MARGARET TIKKANEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 SUPERIOR AVE
BARAGA MI
49908-9673
US

IV. Provider business mailing address

102 SUPERIOR AVE
BARAGA MI
49908-9673
US

V. Phone/Fax

Practice location:
  • Phone: 906-353-8787
  • Fax: 906-353-8799
Mailing address:
  • Phone: 906-353-8787
  • Fax: 906-353-8799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: