Healthcare Provider Details

I. General information

NPI: 1861311136
Provider Name (Legal Business Name): JESSICA LYNN CASTILLO RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 E PARIS AVE SE
GRAND RAPIDS MI
49546-6130
US

IV. Provider business mailing address

1695 CANADA RD
BAILEY MI
49303-9713
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-5980
  • Fax:
Mailing address:
  • Phone: 231-457-6485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902019565
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: