Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2902017535 | MI |
NPI | 1033660154 |
---|---|
Provider Name | Lauren Thacker |
First Address | Warren, MI 48092-6324 |
Second Address | West Bloomfield, MI 48323-1604 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2016 |
Last Update Date | 24/10/2016 |