Provider Demographics
NPI:1376274431
Name:SCHUTZBACH, ILISSA GRACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ILISSA
Middle Name:GRACE
Last Name:SCHUTZBACH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 BARCLAY CIR STE 900
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5817
Mailing Address - Country:US
Mailing Address - Phone:248-852-6430
Mailing Address - Fax:
Practice Address - Street 1:245 BARCLAY CIR STE 900
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5817
Practice Address - Country:US
Practice Address - Phone:248-852-6430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016014141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice