Healthcare Provider Details

I. General information

NPI: 1609234343
Provider Name (Legal Business Name): MICHELLE SPENCER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3894 ROBINA AVE
BERKLEY MI
48072-1499
US

IV. Provider business mailing address

3894 ROBINA AVE
BERKLEY MI
48072-1499
US

V. Phone/Fax

Practice location:
  • Phone: 248-496-7447
  • Fax: 248-439-2900
Mailing address:
  • Phone: 248-496-7447
  • Fax: 248-439-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902017545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: