Provider Demographics
NPI:1558794594
Name:EMMONS, BOBBI RAE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:BOBBI
Middle Name:RAE
Last Name:EMMONS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7040 REED DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1579
Mailing Address - Country:US
Mailing Address - Phone:248-396-6551
Mailing Address - Fax:
Practice Address - Street 1:4727 SAINT ANTOINE ST
Practice Address - Street 2:SUITE 408
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1461
Practice Address - Country:US
Practice Address - Phone:313-833-7309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902011940124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist