Healthcare Provider Details

I. General information

NPI: 1982909206
Provider Name (Legal Business Name): REBECCA HODGE RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

23700 ORCHARD LAKE RD SUITE J
FARMINGTON HILLS MI
48336-2559
US

IV. Provider business mailing address

9945 FOX AVE
ALLEN PARK MI
48101-1394
US

V. Phone/Fax

Practice location:
  • Phone: 248-478-0831
  • Fax: 248-478-8798
Mailing address:
  • Phone: 313-433-0762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902015742
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: