Healthcare Provider Details

I. General information

NPI: 1497522627
Provider Name (Legal Business Name): KAYLA MARIA GLASS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 S GROVE ST APT 108
YPSILANTI MI
48198-5671
US

IV. Provider business mailing address

209 S GROVE ST APT 108
YPSILANTI MI
48198-5671
US

V. Phone/Fax

Practice location:
  • Phone: 734-833-4936
  • Fax:
Mailing address:
  • Phone: 734-833-4936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902020243
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: