Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2902015107 | MI |
NPI | 1003335449 |
---|---|
Provider Name | Lynn M Radka |
First Address | Hillman, MI 49746-0427 |
Second Address | Atlanta, MI 49709-9374 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/09/2017 |
Last Update Date | 16/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003335449 | (05) | MI |