Healthcare Provider Details

I. General information

NPI: 1639552854
Provider Name (Legal Business Name): JAHURA HOBBY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 GRATIOT AVE
DETROIT MI
48207-2372
US

IV. Provider business mailing address

3018 ROOSEVELT ST
HAMTRAMCK MI
48212-3742
US

V. Phone/Fax

Practice location:
  • Phone: 313-393-3009
  • Fax:
Mailing address:
  • Phone: 313-415-3863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902017454
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: