=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477120038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORRINE HOLSBEKE DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2021
-----------------------------------------------------
Last Update Date | 06/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 47 S HOWARD AVE
-----------------------------------------------------
City | CROSWELL
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48422-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-679-3182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66340 OMO RD
-----------------------------------------------------
City | LENOX
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48050-1526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-719-6480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901600987
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------