Healthcare Provider Details

I. General information

NPI: 1407347669
Provider Name (Legal Business Name): EMILY IRENE BUSHONG RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56720 CALUMET AVE
CALUMET MI
49913-1967
US

IV. Provider business mailing address

536 FLORIDA ST
LAURIUM MI
49913-2208
US

V. Phone/Fax

Practice location:
  • Phone: 906-483-1177
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902018455
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: