MEDICARE: TRACI LEE LENTEN RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	2902061784	MI

General Provider Information

NPI Number	:	1346679446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACI LEE LENTEN RDH

Provider Business Mailing Address
First Line	:	218 PINE ST
Second Line	:
City	:	REPUBLIC
State	:	MI
Zip	:	49879-9250
Country	:	US
Telephone Number	:	906-362-7409
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 S 4TH ST STE B
Second Line	:
City	:	CRYSTAL FALLS
State	:	MI
Zip	:	49920-1583
Country	:	US
Telephone Number	:	906-875-6133
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2013
Last Update Date	:	11/08/2013

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