Provider Demographics
NPI:1861865719
Name:MACDONALD, JENNIFER (RDH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MACDONALD
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 1:33533 W 12 MILE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3354
Mailing Address - Country:US
Mailing Address - Phone:888-833-8441
Mailing Address - Fax:
Practice Address - Street 1:33533 W 12 MILE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3354
Practice Address - Country:US
Practice Address - Phone:888-833-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-31
Last Update Date:2015-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902014018124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist