Healthcare Provider Details

I. General information

NPI: 1841541844
Provider Name (Legal Business Name): JENNA PUTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N PINE RIVER ST
ITHACA MI
48847
US

IV. Provider business mailing address

610 N PINE RIVER ST
ITHACA MI
48847
US

V. Phone/Fax

Practice location:
  • Phone: 989-875-2888
  • Fax:
Mailing address:
  • Phone: 989-875-2888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.023844
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901021389
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: