Healthcare Provider Details

I. General information

NPI: 1689126914
Provider Name (Legal Business Name): RYANNE GUMBERT RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RYANNE STROUTH RDH

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 HIGHLAND DR
JACKSON MI
49201-9164
US

IV. Provider business mailing address

5305 HUNT RD
ONONDAGA MI
49264-9712
US

V. Phone/Fax

Practice location:
  • Phone: 517-740-5620
  • Fax:
Mailing address:
  • Phone: 517-358-0784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902016239
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: