1972111060 NPI number — MISS SUSAN MICHELLE PICKETT DENTAL HYGIENIST

Table of content: MISS SUSAN MICHELLE PICKETT DENTAL HYGIENIST (NPI 1972111060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972111060 NPI number — MISS SUSAN MICHELLE PICKETT DENTAL HYGIENIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PICKETT
Provider First Name:
SUSAN
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
DENTAL HYGIENIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972111060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
544 PINE KNOLL CIR APT 2A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATTLE CREEK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49014-7719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-578-6888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 W PATERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49007-2557
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-349-2641
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  2902008760 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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