Healthcare Provider Details

I. General information

NPI: 1669636072
Provider Name (Legal Business Name): LYNN MICHELLE EICKHOLT D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2008
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 W GRAND BLVD
DETROIT MI
48216-2200
US

V. Phone/Fax

Practice location:
  • Phone: 313-554-3880
  • Fax: 313-899-3550
Mailing address:
  • Phone: 313-554-0485
  • Fax: 313-228-0283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901019857
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: