MEDICARE: MARISA MATTHEWS

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	2902017954	MI

General Provider Information

NPI Number	:	1346794708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA MATTHEWS

Provider Business Mailing Address
First Line	:	5780 EAGLE RD
Second Line	:
City	:	WHITE LAKE
State	:	MI
Zip	:	48383-1210
Country	:	US
Telephone Number	:	248-961-0438
Fax Number	:

Provider Business Practice Location Address
First Line	:	5780 EAGLE RD
Second Line	:
City	:	WHITE LAKE
State	:	MI
Zip	:	48383-1210
Country	:	US
Telephone Number	:	248-961-0438
Fax Number	:

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

Provider Enumeration Date	:	08/15/2016
Last Update Date	:	08/15/2016

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Directions to “ MARISA MATTHEWS ” Practice Location

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