MEDICARE: MRS. JESSICA LEE VIDETICH 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	L485276	MI

General Provider Information

NPI Number	:	1528430477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA LEE VIDETICH RDH

Provider Business Mailing Address
First Line	:	2700 BAKER ST
Second Line	:
City	:	MUSKEGON HTS
State	:	MI
Zip	:	49444-2157
Country	:	US
Telephone Number	:	231-737-8603
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 BAKER ST
Second Line	:
City	:	MUSKEGON HTS
State	:	MI
Zip	:	49444-2157
Country	:	US
Telephone Number	:	231-737-8603
Fax Number	:

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

Provider Enumeration Date	:	10/30/2015
Last Update Date	:	10/30/2015

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