Healthcare Provider Details

I. General information

NPI: 1790286664
Provider Name (Legal Business Name): MARY PAIGE FOURNIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 02/26/2018
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

50276 ANDERS ST
CHESTERFIELD MI
48047-1905
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 Number2902017216
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: