Healthcare Provider Details

I. General information

NPI: 1215353065
Provider Name (Legal Business Name): TRACIE HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2014
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 EMMETT ST W
BATTLE CREEK MI
49037-2963
US

IV. Provider business mailing address

181 EMMETT ST W
BATTLE CREEK MI
49037-2963
US

V. Phone/Fax

Practice location:
  • Phone: 269-965-8866
  • Fax:
Mailing address:
  • Phone: 269-965-8866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902011443
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: