Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | MI |
NPI | 1013409713 |
---|---|
Provider Name | Diane Magnus |
First Address | Otisville, MI 48463-9486 |
Second Address | Otisville, MI 48463-9486 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/05/2018 |
Last Update Date | 30/05/2018 |