Healthcare Provider Details

I. General information

NPI: 1427537695
Provider Name (Legal Business Name): MYRNA BAUTISTA BOOTH RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2837 STABLE DR STE A
KIMBALL MI
48074-1441
US

IV. Provider business mailing address

4047 STONEY CREEK DR
FORT GRATIOT MI
48059-3741
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-3301
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: