Provider Demographics
NPI:1972111060
Name:PICKETT, SUSAN MICHELLE (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:MICHELLE
Last Name:PICKETT
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 PINE KNOLL CIR APT 2A
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49014-7719
Mailing Address - Country:US
Mailing Address - Phone:269-578-6888
Mailing Address - Fax:
Practice Address - Street 1:117 W PATERSON ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-2557
Practice Address - Country:US
Practice Address - Phone:269-349-2641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902008760124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist