Basic Information
| Provider Information | |||||||||
| NPI: | 1972111060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICKETT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | DENTAL HYGIENIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 544 PINE KNOLL CIR APT 2A | ||||||||
| Address2: | |||||||||
| City: | BATTLE CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490147719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695786888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 117 W PATERSON ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490072557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693492641 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2020 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 2902008760 | MI | Y | Dental Providers | Dental Hygienist |
No ID Information.