Healthcare Provider Details

I. General information

NPI: 1598160483
Provider Name (Legal Business Name): FERRIS STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FERRIS DR
BIG RAPIDS MI
49307-2740
US

IV. Provider business mailing address

200 FERRIS DR
BIG RAPIDS MI
49307-2740
US

V. Phone/Fax

Practice location:
  • Phone: 231-591-3130
  • Fax:
Mailing address:
  • Phone: 231-591-3130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901018836
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902011248
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902002544
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902004089
License Number StateMI

VIII. Authorized Official

Name: MS. JAMIE FREITAG
Title or Position: SEALANT COORDINATOR
Credential: RDH
Phone: 231-591-3130