Provider Demographics
NPI:1619094224
Name:HERMAN, AUDRA ZACKAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:AUDRA
Middle Name:ZACKAY
Last Name:HERMAN
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 1:25520 LITTLE MACK AVE.
Mailing Address - Street 2:
Mailing Address - City:ST. CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081
Mailing Address - Country:US
Mailing Address - Phone:586-771-5888
Mailing Address - Fax:586-777-7319
Practice Address - Street 1:25520 LITTLE MACK AVE.
Practice Address - Street 2:
Practice Address - City:ST. CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081
Practice Address - Country:US
Practice Address - Phone:586-771-5888
Practice Address - Fax:586-777-7319
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010193711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice