Healthcare Provider Details

I. General information

NPI: 1588152862
Provider Name (Legal Business Name): SARA DELENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S 7TH ST STE A
ONTONAGON MI
49953-1497
US

IV. Provider business mailing address

17229 BARAGA PLAINS RD
BARAGA MI
49908-9157
US

V. Phone/Fax

Practice location:
  • Phone: 906-884-6032
  • Fax:
Mailing address:
  • Phone: 906-353-6655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902009144
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: