Provider Demographics
NPI:1699450247
Name:HORNICK, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:HORNICK
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 1:23941 JOHN R RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-1416
Mailing Address - Country:US
Mailing Address - Phone:248-547-2055
Mailing Address - Fax:
Practice Address - Street 1:23941 JOHN R RD
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030-1416
Practice Address - Country:US
Practice Address - Phone:248-547-2055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601834390200000X, 1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program