Healthcare Provider Details

I. General information

NPI: 1184186025
Provider Name (Legal Business Name): MELISSA ANN HUTTENGA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 ORCHARD HWY
MANISTEE MI
49660-9754
US

IV. Provider business mailing address

2840 ORCHARD HWY
MANISTEE MI
49660-9754
US

V. Phone/Fax

Practice location:
  • Phone: 231-398-2258
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902015790
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: