Provider Demographics
NPI:1780002014
Name:HULBERT, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:HULBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 LAKESHORE DR APT 402
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23200 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-7754
Practice Address - Country:US
Practice Address - Phone:269-668-6715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3360778124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist