Healthcare Provider Details

I. General information

NPI: 1336598135
Provider Name (Legal Business Name): MARCY JUNGBLUT R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W PATERSON ST
KALAMAZOO MI
49007-2557
US

IV. Provider business mailing address

117 W PATERSON ST
KALAMAZOO MI
49007-2557
US

V. Phone/Fax

Practice location:
  • Phone: 269-349-4257
  • Fax:
Mailing address:
  • Phone: 269-349-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902011391
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: