Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223D0001X | Dental Public Health | 019027489 | IL |
Y | 1223D0001X | Dental Public Health | 2901022416 | MI |
N | 1223G0001X | General Practice | 2901022416 | MI |
N | 213EG0000X | General Practice | 2901022416 | MI |
NPI | 1326235904 |
---|---|
Provider Name | Lucy J Opris |
First Address | Berkley, MI 48072-1630 |
Second Address | Berkley, MI 48072-1630 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2007 |
Last Update Date | 08/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
13501447 | CAQH (01) | MI |
1780096792 | TYPE 2 NPI (01) | MI |
20170171 | MOBILE DENTAL PERMIT (01) | MI |
PA161 | PA161 (01) | MI |