Provider Demographics
NPI:1518640432
Name:MEREDITH, IESHA QUINETTA
Entity Type:Individual
Prefix:MS
First Name:IESHA
Middle Name:QUINETTA
Last Name:MEREDITH
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 1:3256 BURLINGAME ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-1436
Mailing Address - Country:US
Mailing Address - Phone:313-648-3081
Mailing Address - Fax:
Practice Address - Street 1:18 MARKET ST STE C
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-7403
Practice Address - Country:US
Practice Address - Phone:586-783-2222
Practice Address - Fax:786-229-1223
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902014413124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist