Healthcare Provider Details

I. General information

NPI: 1750737821
Provider Name (Legal Business Name): SELICE JENAE ZOOPER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4727 SAINT ANTOINE ST SUITE 408
DETROIT MI
48201-1461
US

IV. Provider business mailing address

4727 SAINT ANTOINE ST SUITE 408
DETROIT MI
48201-1461
US

V. Phone/Fax

Practice location:
  • Phone: 313-833-7309
  • Fax:
Mailing address:
  • Phone: 313-833-7309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: