Healthcare Provider Details

I. General information

NPI: 1154870228
Provider Name (Legal Business Name): MRS. MELISSA ANN YEAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 MAIN ST
GREEN BAY WI
54302-3920
US

IV. Provider business mailing address

2050 E ALGONQUIN RD
SCHAUMBURG IL
60173-4144
US

V. Phone/Fax

Practice location:
  • Phone: 888-988-4066
  • Fax:
Mailing address:
  • Phone: 847-915-3044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1002827
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: