Provider Demographics
NPI:1306455282
Name:DERUITER, COURTNEY (RDH)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:DERUITER
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 1:23280 N ROSEDALE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2615
Mailing Address - Country:US
Mailing Address - Phone:313-549-3822
Mailing Address - Fax:
Practice Address - Street 1:37304 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BEAVER ISLAND
Practice Address - State:MI
Practice Address - Zip Code:49782-5134
Practice Address - Country:US
Practice Address - Phone:231-547-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902019194124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist