Provider Demographics
NPI:1346660297
Name:ROLLMAN, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ROLLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SCHOFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54476-5113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:128 OLD ABE RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-9386
Practice Address - Country:US
Practice Address - Phone:715-588-4269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5486-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist