Healthcare Provider Details

I. General information

NPI: 1346679446
Provider Name (Legal Business Name): TRACI LEE LENTEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S 4TH ST STE B
CRYSTAL FALLS MI
49920-1583
US

IV. Provider business mailing address

218 PINE ST
REPUBLIC MI
49879-9250
US

V. Phone/Fax

Practice location:
  • Phone: 906-875-6133
  • Fax:
Mailing address:
  • Phone: 906-362-7409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902061784
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: