MEDICARE: MRS. KEISHA DENISE PARKS 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	2902015144	MI

General Provider Information

NPI Number	:	1932502077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KEISHA DENISE PARKS RDH

Provider Business Mailing Address
First Line	:	5379 CRANE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48213-2918
Country	:	US
Telephone Number	:	313-405-8972
Fax Number	:

Provider Business Practice Location Address
First Line	:	5379 CRANE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48213-2918
Country	:	US
Telephone Number	:	313-405-8972
Fax Number	:

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

Provider Enumeration Date	:	10/03/2014
Last Update Date	:	10/03/2014

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