=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609234343
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE SPENCER RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2016
-----------------------------------------------------
Last Update Date | 02/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3894 ROBINA AVE
-----------------------------------------------------
City | BERKLEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48072-1499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-496-7447
-----------------------------------------------------
Fax | 248-439-2900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3894 ROBINA AVE
-----------------------------------------------------
City | BERKLEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48072-1499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-496-7447
-----------------------------------------------------
Fax | 248-439-2900
-----------------------------------------------------
=====================================================
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 | 2902017545
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------