Healthcare Provider Details

I. General information

NPI: 1285133355
Provider Name (Legal Business Name): KELLY L KOCSIS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY L JACOBI RDH

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 N MICHIGAN AVE
SAGINAW MI
48602-4314
US

IV. Provider business mailing address

427 N MICHIGAN AVE
SAGINAW MI
48602-4314
US

V. Phone/Fax

Practice location:
  • Phone: 989-755-0991
  • Fax: 989-755-0001
Mailing address:
  • Phone: 989-755-0991
  • Fax: 989-755-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902014206
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: