Healthcare Provider Details

I. General information

NPI: 1467037812
Provider Name (Legal Business Name): MELISSA ROXANE PURUCKER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N JACKSON ST
JACKSON MI
49201-1223
US

IV. Provider business mailing address

1133 25 MILE RD
HOMER MI
49245-9641
US

V. Phone/Fax

Practice location:
  • Phone: 517-748-5500
  • Fax:
Mailing address:
  • Phone: 517-945-6118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902013670
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: