Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2902015997 | MI |
NPI | 1033690425 |
---|---|
Provider Name | Raquel Potter |
First Address | Macomb, MI 48042-4114 |
Second Address | Macomb, MI 48042-4114 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2018 |
Last Update Date | 24/08/2018 |