Healthcare Provider Details

I. General information

NPI: 1770958787
Provider Name (Legal Business Name): KRISTIN LEIGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51299 ROMEO PLANK RD
MACOMB MI
48042-4114
US

IV. Provider business mailing address

18298 CIDER MILL ST
MACOMB MI
48044-4137
US

V. Phone/Fax

Practice location:
  • Phone: 586-697-5272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902017680
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: