Healthcare Provider Details

I. General information

NPI: 1528409117
Provider Name (Legal Business Name): DIANA LEE KOTT RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43401 N JEFFERSON AVE BLDG 825
SELFRIDGE ANGB MI
48045-5266
US

IV. Provider business mailing address

43401 N JEFFERSON AVE BLDG 825
SELFRIDGE ANGB MI
48045-5266
US

V. Phone/Fax

Practice location:
  • Phone: 586-239-3005
  • Fax:
Mailing address:
  • Phone: 586-239-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902011643
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: