=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215806310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLEE MCCRACKEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2025
-----------------------------------------------------
Last Update Date | 11/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7166 S CROTON HARDY DR
-----------------------------------------------------
City | NEWAYGO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49337-7707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-652-1663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4997 E 8TH ST
-----------------------------------------------------
City | WHITE CLOUD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49349-9583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 2902020762
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------