Provider Demographics
NPI:1962864934
Name:MUPOTSA, EMMA L (RDH)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:L
Last Name:MUPOTSA
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 1:50 INDUSTRIAL PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013
Mailing Address - Country:US
Mailing Address - Phone:269-427-7937
Mailing Address - Fax:269-427-5180
Practice Address - Street 1:6270 W MAIN ST
Practice Address - Street 2:INTERCARE COMMUNITY HEALTH NETWORK
Practice Address - City:EAU CLAIRE
Practice Address - State:MI
Practice Address - Zip Code:49111-9480
Practice Address - Country:US
Practice Address - Phone:269-461-6927
Practice Address - Fax:269-461-3068
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902017595124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist