Provider Demographics
NPI:1356788483
Name:BELLISSIMO, MARY BETH (DENTAL HYGIENIST)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:BELLISSIMO
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 1:5095 RIFLE RIVER TRL
Mailing Address - Street 2:
Mailing Address - City:ALGER
Mailing Address - State:MI
Mailing Address - Zip Code:48610-9327
Mailing Address - Country:US
Mailing Address - Phone:989-873-5152
Mailing Address - Fax:989-873-5913
Practice Address - Street 1:5095 RIFLE RIVER TRL
Practice Address - Street 2:
Practice Address - City:ALGER
Practice Address - State:MI
Practice Address - Zip Code:48610-9327
Practice Address - Country:US
Practice Address - Phone:989-873-5152
Practice Address - Fax:989-873-5913
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902007920124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist