Healthcare Provider Details

I. General information

NPI: 1366183337
Provider Name (Legal Business Name): REBECCA LEE REIFERT RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3037 ELECTRIC AVE
PORT HURON MI
48060-6615
US

IV. Provider business mailing address

6548 GALBRAITH LINE RD
CROSWELL MI
48422-9123
US

V. Phone/Fax

Practice location:
  • Phone: 810-984-5197
  • Fax:
Mailing address:
  • Phone: 810-712-7175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902011825
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: