Healthcare Provider Details

I. General information

NPI: 1780002014
Provider Name (Legal Business Name): MELISSA HULBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23200 RED ARROW HWY
MATTAWAN MI
49071-7754
US

IV. Provider business mailing address

2700 LAKESHORE DR APT 402
SAINT JOSEPH MI
49085-2268
US

V. Phone/Fax

Practice location:
  • Phone: 269-668-6715
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number3360778
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: