Healthcare Provider Details

I. General information

NPI: 1699387480
Provider Name (Legal Business Name): KYLIE JANAE MIX RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10767 E TRAVERSE HWY
TRAVERSE CITY MI
49684-6219
US

IV. Provider business mailing address

10767 E TRAVERSE HWY
TRAVERSE CITY MI
49684-6219
US

V. Phone/Fax

Practice location:
  • Phone: 231-947-1112
  • Fax: 231-947-7739
Mailing address:
  • Phone: 231-947-1112
  • Fax: 231-947-7739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902012893
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: