Healthcare Provider Details

I. General information

NPI: 1548546898
Provider Name (Legal Business Name): KATHRYN LOUISE ROEHLING D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN LOUISE LUCAS D.D.S.

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5716 MICHIGAN AVE
DETROIT MI
48210-3039
US

IV. Provider business mailing address

559 WEST GRAND BLVD.
DETROIT MI
48216
US

V. Phone/Fax

Practice location:
  • Phone: 313-554-3880
  • Fax: 313-899-3550
Mailing address:
  • Phone: 313-228-2400
  • Fax: 313-228-0204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901020426
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: