Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 2951000663 | MI |
NPI | 1003478959 |
---|---|
Provider Name | Alexandra Hensen |
First Address | Iron Mountain, MI 49801-4760 |
Second Address | Iron Mountain, MI 49801-4760 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2019 |
Last Update Date | 18/08/2020 |