Healthcare Provider Details

I. General information

NPI: 1205654704
Provider Name (Legal Business Name): ANGELA D SHEDD RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 MARSHALL RD
COLDWATER MI
49036-8252
US

IV. Provider business mailing address

1574 19 MILE RD
TEKONSHA MI
49092-9203
US

V. Phone/Fax

Practice location:
  • Phone: 517-279-9561
  • Fax:
Mailing address:
  • Phone: 517-677-8477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902016098
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: