Healthcare Provider Details

I. General information

NPI: 1326164609
Provider Name (Legal Business Name): JENNIFER KUESTER MERTZ D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18342 MACK AVE
GROSSE POINTE FARMS MI
48236-3219
US

IV. Provider business mailing address

32981 BROOKSIDE CIR
LIVONIA MI
48152-1426
US

V. Phone/Fax

Practice location:
  • Phone: 313-881-2480
  • Fax:
Mailing address:
  • Phone: 734-786-0108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901018842
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: