Healthcare Provider Details

I. General information

NPI: 1285520148
Provider Name (Legal Business Name): MALIAH JOHNSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 N MAPLE ST
GRANT MI
49327-7900
US

IV. Provider business mailing address

1615 MICHIGAN AVE
BALDWIN MI
49304-7984
US

V. Phone/Fax

Practice location:
  • Phone: 231-834-9750
  • Fax: 231-745-0412
Mailing address:
  • Phone: 231-745-2736
  • Fax: 231-745-0412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902021302
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: