Healthcare Provider Details

I. General information

NPI: 1760799456
Provider Name (Legal Business Name): BETSY LYNN SOUTHERN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2010
Last Update Date: 09/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7040 MCKAY RD
JACKSON MI
49201-9261
US

IV. Provider business mailing address

7040 MCKAY RD
JACKSON MI
49201-9261
US

V. Phone/Fax

Practice location:
  • Phone: 517-740-5620
  • Fax: 517-563-0957
Mailing address:
  • Phone: 517-740-5620
  • Fax: 517-563-0957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902011118
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: