Provider Demographics
NPI:1679946263
Name:DIVIC, SANKA (RDH)
Entity type:Individual
Prefix:
First Name:SANKA
Middle Name:
Last Name:DIVIC
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 1:2453 BLUFF MEADOWS DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7910
Mailing Address - Country:US
Mailing Address - Phone:616-956-9265
Mailing Address - Fax:
Practice Address - Street 1:2055 ROSEWOOD AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-5248
Practice Address - Country:US
Practice Address - Phone:616-776-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902014498124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist