December 8, 2017 Michigan Department of Health and Human Services Page 1 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Allegan Rik Tooker MD 1154385672 Allegan County Health Dept 3255 122nd Ave. Ste 200 Allegan, MI 49010 Allegan Cassie Plockmeyer NP 1518385129 Allegan Professional Health Services 551 Linn Street Allegan, MI 49010 Allegan Sara Franzen MD 1871735522 Allegan Professional Health Services 551 Linn Street Allegan, MI 49010 Allegan William Davis MD 1629130703 Allegan Professional Health Services 551 Linn Street Allegan, MI 49010 Allegan Tom Saad waiting on cert from MD 1417908930 Borgess Family Medicine & Pediatrics 345 Naomi Street Plainwell, MI 49080 Altarum Allegan, Ottawa Allison Rund MD 1164685608 Spectrum Health Med Group- Holland 588 E. Lakewood Blvd. Holland, MI 49424 Allegan, Ottawa Erin Michelle Walton CPNP-PC, 1669847703 Spectrum Health Med Group- Holland 588 E. Lakewood Blvd. Holland, MI 49424 BSN, RN Allegan, Ottawa Nancy MacDonald MD 1114960150 Spectrum Health Med Group- Holland 588 E. Lakewood Blvd. Holland, MI 49424 Allegan, Ottawa Wendy Pytlak Zink DO 1760450928 Spectrum Health Med Group- Holland 588 E. Lakewood Blvd. Holland, MI 49424 Alpena Christy Werth DO 1750390498 Alpena Medical Arts, P.C. 211 Long Rapids Rd. Alpena, MI 49707 Alpena James Decker MD 1497749576 Alpena Medical Arts, P.C. 211 Long Rapids Rd. Alpena, MI 49707 Alpena Kathleen Phillips NP 1497099667 Alpena Medical Arts, P.C. 211 Long Rapids Rd. Alpena, MI 49707 Alpena Rong Lawson MD 1215116025 Alpena Medical Arts, P.C. 211 Long Rapids Rd. Alpena, MI 49707 Antrim Albert Brown MD 1174516744 Mancelona Family Practice 419 W. State St. Mancelona, MI 49659 Antrim Jennifer Leino MD 1588648539 Mancelona Family Practice 419 W. State St. Mancelona, MI 49659 Arenac Brodi Lynch MD 1285958223 Standish Family Medicine 805 W. Cedar Standish, MI 48658 Arenac Ceaser Casten MD 1962440511 Standish Family Medicine 805 W. Cedar Standish, MI 48658 Baraga Sharon Gilliland MD 1669479390 BCMH Physician Group 18341 US Hwy 41 L'Anse, MI 49946 Barry David Halley MD Borgess Family Medicine 345 Naomi St Plainwell MI 49080 Barry Nehdia Hashemi MD 1295014124 Borgess Family Medicine 345 Naomi St Plainwell MI 49080 Barry Thomas Akland DO 1205873056 Borgess Health- Family Medicine and Pediatrics 345 Naomi St Plainwell MI 49080 Barry Amy Beck MD 1740244144 Bright Start Pediatrics 1375 W. Green St. Hastings, MI 49058 Barry Amanda Rathburn FNP-BC 1750716593 Ingham Well Child 901 E. Mt. Hope Rd. Lansing, MI 48910 Bay Bhaskar Devanagondi MD 1386704419 Bay Pediatric Clinic 2110 16th Street Bay City, MI 48708 Bay Bilugali Sundara MD 1437219540 Bay Pediatric Clinic 2110 16th Street Bay City, MI 48708 Bay Inez Balinska 1831171230 Bay Regional Pediatrics 1456 W. Center Rd. Suite 1 Essexville, MI 48732 Bay Donna Hammond NP 1366438996 Children's Medical Group of Saginaw Bay-Bay City 248 Washington Ave. Bay City, MI 48708 Bay Jeffrey VanGelderen MD 1043217979 Children's Medical Group of Saginaw Bay-Bay City 248 Washington Ave. Bay City, MI 48708 Bay Ariadne Lie MD 1245243484 GLBHC-Bayside 3884 Monitor Road Bay City, MI 48706 Bay Barbara Kish NP 1902894769 GLBHC-Bayside 3884 Monitor Road Bay City, MI 48706 Bay Gary Tamez DO 1265422356 GLBHC-Bayside 3884 Monitor Road Bay City, MI 48706 Bay Heather Prior NP 1821377748 GLBHC-Bayside 3884 Monitor Road Bay City, MI 48706 Bay Kristie Smith NP 1700339249 GLBHC-Bayside 3884 Monitor Road Bay City, MI 48706 Bay Alexandria M. Smits DO 1104230358 McLaren Bay Family Health & Wellness Center 1458 W. Center Road, Suite 5 Essexville, MI 48732 Bay Andrew A. Whiteside DO 1710330634 McLaren Bay Family Health & Wellness Center 1458 W. Center Road, Suite 5 Essexville, MI 48732 Bay Dustin James DO 1952857872 McLaren Bay Family Health & Wellness Center 1458 W. Center Road, Suite 5 Essexville, MI 48732 Bay Jessica Neuroth DO 1487036513 McLaren Bay Family Health & Wellness Center 1458 W. Center Road, Suite 5 Essexville, MI 48732 Bay Maria Lawrence DO 1942263801 McLaren Bay Family Health & Wellness Center 1458 W. Center Road, Suite 5 Essexville, MI 48732 Bay Marilyn Nguyen DO 1457704371 McLaren Bay Family Health & Wellness Center 1458 W. Center Road, Suite 5 Essexville, MI 48732 Bay Suhaylah Mohiuddin DO 1710369830 McLaren Bay Family Health & Wellness Center 1458 W. Center Road, Suite 5 Essexville, MI 48732 Bay Darius Balinski 1891777892 McLaren Bay Region 1456 W. Center Rd. Suite 1 Essexville, MI 48732 Bay MaryAnne Putt NP 1992859250 McLaren Bay Region - Auburn Family Medicine 312 E. Midland Rd. Auburn, MI 48611 Bay Stacey Williamson NP 1548528086 Pinconning Family Medicine 204 W. 3rd St. Pinconning, MI 48650 Benzie Jennifer Dankers NP 1477820983 Crystal Lake Health Clinic Benzonia 6227 Frankfort Hwy. Benzonia, MI 49616 Berrien Dr. Barbara Boyd MD 1417981549 Intercare Community Health Network 960 Agard St. Benton Harbor, 49022 December 8, 2017 Michigan Department of Health and Human Services Page 2 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Branch Mehalai Arivoli MD 1346274891 Branch Pediatric and Adolescent Medicine 360 East Chicago St. Suite 101 Coldwater, MI 49036 Branch Arivoli Veerappan MD 1306873658 CHC Pedicatrics 391 Northshore Dr. Coldwater, MI 49036 Branch H Lauren Vogel DO 1396770020 Family Medicine Clinic 292 E. Chicago St. Coldwater 49036 Branch Srijaya Bandi MD 1295907525 Family Medicine Clinic 292 East Chicago St. Suite 200 Coldwater 49036 Branch William K Stewart MD 1033147863 Family Medicine Clinic 292 E. Chicago St. Coldwater 49036 Calhoun David M. Byrens MD 1902874126 David M. Byrens, MD 215 E. Mansion St, Ste 1G Marshall, MI 49068 Calhoun Elizabeth Mettler MD 1215139449 Grace Health 181 W. Emmett St. Battle Creek, MI 49037-2963 Calhoun Emilie Rabb RN, CPNP 1851763668 Grace Health 181 W. Emmett St. Battle Creek, MI 49037-2963 Calhoun Karen Garcia DO 1891954400 Grace Health 181 W. Emmett St. Battle Creek, MI 49037-2963 Calhoun Kelli Collins DO 1598056251 Grace Health 181 W. Emmett St. Battle Creek, MI 49037-2963 Calhoun Linda Wetherbee RN, CPNP 1982666350 Grace Health 181 W. Emmett St. Battle Creek, MI 49037-2963 Calhoun Mark Richardson MD 1669449443 Mark D. Richardson MD PC 215 E. Mansion St, Ste 1G Marshall, MI 49068 Calhoun Jaime Viers NP 1568878452 Northside Pediatrics 265 Fremont St, #1 Battle Creek, MI 49017 Calhoun Jose R. Ayola MD 1265491831 Northside Pediatrics 265 Fremont St, #1 Battle Creek, MI 49017 Calhoun Krystyna B. Malec MD 1295794915 Northside Pediatrics 265 Fremont St, #1 Battle Creek, MI 49017 Charlevoix Roderic Tinney MD 1538151212 Munson Health Care Charlevoix Pediatrics 14719 W. Upright St. Charlevoix, MI 49720 Charlevoix Benjamin Edwards MD 1548606916 Munson Health Care Charlevoix Primary Care 14734 Park Ave. Charlevoix, MI 49720 Charlevoix Chris Loewen MD 1114368321 Munson Health Care Charlevoix Primary Care 14734 Park Ave. Charlevoix, MI 49720 Charlevoix Jean Mcdonough NP 1295035244 Munson Health Care Charlevoix Primary Care 14734 Park Ave. Charlevoix, MI 49720 Cheboygan Cathy Nowka NP 1902988777 Mackinac Straits Health System-Mackinaw City Medical 420 South Nicolet Street Mackinaw City, MI 49701 Clinic Cheboygan Roderick Baltzer DO 1760564041 Mackinac Straits Health System-Mackinaw City Medical 420 South Nicolet Street Mackinaw City, MI 49701 Clinic Chippewa Joseph Garlinghouse MD 1649219932 Chippewa Co Health Dept 508 Ashmun St. Suite 120, Sault Saint, MI 49783 Crawford Kristie H. Koehler MD 1174856785 Munson Health Care Grayling Hospital 1250 E. Michigan Avenue Grayling, MI 49738 Eaton Anne Khol NP 1770791246 Eaton Rapids Medical Center and Family Practice 1500 South Main Street Eaton Rapids, MI 48827 Eaton Harshini Jayasuriya MD 1043507833 Eaton Rapids Medical Center and Family Practice 1500 South Main Street Eaton Rapids, MI 48827 Eaton Julie Coenen NP 1053424150 Family Care Specialists 111 Lansing Street Eaton Todd Otten MD 1710967930 Family Care Specialists 111 Lansing Street Eaton Linda Murray Chermak MD 1619209442 Hayes Green Beach Health (HGB) 111 Lansing St. Suite 230 Charlotte, MI 48813 Eaton Stephanie Kramer NP 1518399484 Hayes Green Beach Health (HGB) 111 Lansing St. Suite 230 Charlotte, MI 48813 Eaton Jennifer Boote DO 1518129527 MSU Westside Pediatrics 7335 Westshire Drive Lansing, MI 48917 Eaton Joel Greenberg DO 1194838581 MSU Westside Pediatrics 7335 Westshire Drive Lansing, MI 48917 Eaton Robert Root DO 1043472665 MSU Westside Pediatrics 7335 Westshire Drive Lansing, MI 48917 Emmet Joshua Meyerson MD 1851383533 Little Traverse Bay Band Health Clinic 1250 Lears Road Petoskey, MI 49770 Genesee MUSTAFA GOKAY AKPINAR MD 1497703722 Akpinar Children's Clinic PC 2303 Stonebridge Dr. Bldg A Flint, MI 48532 Genesee Shivani Choudhary MD 1316130172 All Star Pediatrics 8203 S. Saginaw St Grand Blanc, MI 48439 Genesee Kamal Hasan MD 1427150168 Davison Pediatrics 1260 N. Irish Road, Suite A Flint, MI 48423 Genesee Elnahdl Saeed MD 1841216546 E. Saeed MD PC 2 Hurley Plaza, Suite 108 Flint, MI 48503 Genesee Luisa Schlaud NP 1780991877 E. Saeed MD PC 2 Hurley Plaza, Suite 108 Flint, MI 48503 Genesee Milton Holloway MD 1588615660 Flint Children's Center 5205 Norko Drive Flint, MI 48507 Genesee Rajalakshmi Sankaran MD 1124130299 Flint Children's Center 5205 Norko Drive Flint, MI 48507 Genesee Sudha Damidi MD 1407902869 Flint Children's Center 5205 Norko Drive Flint, MI 48507 Genesee Vina Patel MD 1639120660 Flint Children's Center 5205 Norko Drive Flint, MI 48507 Genesee Abdel Abajaj MD 1134108921 Flint Pediatrics 1110 South Linden Road, Suite 7 Flint, MI 48532 Genesee Gary K. Johnson MD 1083752802 Genesee CO HD G3373 S. Saginaw Burton, MI Genesee Jory July NP 1841540358 Genesee CO HD G3373 S. Saginaw Burton, MI Genesee Manar Hammoud MD 1730130279 Genesee Pediatrics G-5119 W. Bristol Road Flint, MI 48507 Genesee Hytham Fadl MD 1386664597 Hurley Children's Clinic 1 Hurley Plaza Flint, MI 48503 Genesee TinTin Manuela-Abad MD 1508178393 Hurley Children's Clinic 1 Hurley Plaza Flint, MI 48503 Genesee Vishwas Vaniawala MD 1639379274 Hurley Children's Clinic 1 Hurley Plaza Flint, MI 48503 Genesee Allison Schnepp MD 1073924510 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Amani Hassan MD 1265713234 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Anthony Vida MD 1710398359 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 December 8, 2017 Michigan Department of Health and Human Services Page 3 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Genesee Ayesha Phillip MD 1518308659 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Candice Mansoor MD 1821408790 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Carline Mbeumo MD 1104268168 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Carline Mbeumo MD 1104268168 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Dunya Mohammad MD 1053796409 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Dustin Miller MD 1225440274 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Elizabeth Schut MD 1366883522 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Florence Ugboh MD 1801276209 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Gwen Reyes MD 1972944809 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Gwendolyn Reyes MD 1972944809 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Harveer Mann MD 1104263060 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Hind Hadid with Altarum MD 1720427743 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 8/14/15 Genesee Hytham Fadl MD 1386664597 Hurley Medical Center 1 Hurley Plaza Pediatrics 3A West Flint MI 48503-5902 Genesee Israa Khan MD 1588942171 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Judenia Aririguzo MD 1801237854 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Judenia Aririguzo MD 1801237854 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Kirti Manjrekar MD 1588005268 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Komalben Parmar MD 1023491735 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Mahmoud Shaqteh MD 1972857043 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Meggan Shell MD 1912384512 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Mona Hanna-Attish MD 1265470348 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Nadine Peart MD 1750777363 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Oliver Atar MD 1508206673 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Poonam Mahajan MD 1184903106 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Sami Al-Harastami MD 1922495043 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Sarah Ramiz MD 1881959146 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Shaheen Sheikh MD 1780014373 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Shaleak Brown MD 1861812588 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Shephali Malhortra MD 4301103193 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Sneha Rao MD 1154601276 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Sriranjani Bajjuri MD 1811275209 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Stephanie Jugmohan MD 1962816876 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Tintin Manuela-Abad MD 1508178393 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Vaishali Khetarpal MD 1245585280 Hurley Medical Center 1 Hurley Plaza Flint MI 48503 Genesee Whei Lim MD 1447668942 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Xinyue Pan MD 1518374131 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Zain Alamarat MD 1215341151 Hurley Medical Center 1 Hurley Plaza Flint, MI 48503 Genesee Emaad Basith MD 1689025108 McLaren Family Residency Flint G3230 Beecher Rd. Ste1 Flint, MI 48532 Genesee Gul-E-Ruku Fendousi MD 1003267527 McLaren Family Residency Flint G3230 Beecher Rd. Ste1 Flint, MI 48532 Genesee Mischa Pollard MD 1154304798 McLaren Family Residency Flint G3230 Beecher Rd. Ste1 Flint, MI 48532 Genesee Paul Lazar MD 1720061328 McLaren Family Residency Flint G3230 Beecher Rd. Ste1 Flint, MI 48532 Genesee Prabhat Pokhrel MD 1871531848 McLaren Family Residency Flint G3230 Beecher Rd. Ste 1 Flint, MI 48532 Genesee Raathathulaki Krishnamahan MD 1992156418 McLaren Family Residency Flint G3230 Beecher Rd. Ste1 Flint, MI 48532 Genesee Rabia Chaudry MD 1306251608 McLaren Family Residency Flint G3230 Beecher Rd. Ste1 Flint, MI 48532 Genesee Raza Cheema MD 1891178760 McLaren Family Residency Flint G3230 Beecher Rd. Ste1 Flint, MI 48532 Genesee Rose Hall DO 1417394230 McLaren Family Residency Flint G3230 Beecher Rd. Ste 1 Flint, MI 48532 Genesee Shannon Slavsky MD 1750796066 McLaren Family Residency Flint G3230 Beecher Rd. Ste1 Flint, MI 48532 Genesee Siddharth Vannemreddy MD 1184007072 McLaren Family Residency Flint G3230 Beecher Rd. Ste1 Flint, MI 48532 Genesee Syed Zaidi MD 1225480932 McLaren Family Residency Flint G3230 Beecher Rd. Ste1 Flint, MI 48532 Genesee Venkata Udaygiri MD McLaren Family Residency Flint G3230 Beecher Rd. Ste1 Flint, MI 48532 Genesee Brian Beck DO 1841288909 Michigan Health Specialists-Dort Hwy 5494 S. Dort Hwy. Flint, MI 48507 Genesee Dennis Reiche NP 1548327760 Michigan Health Specialists-Dort Hwy 5494 S. Dort Hwy. Flint, MI 48507 Genesee Joyce Stevens MD 1346332400 Michigan Health Specialists-Dort Hwy 5494 S. Dort Hwy. Flint, MI 48507 December 8, 2017 Michigan Department of Health and Human Services Page 4 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Genesee Pamela Dasher MD 1952378358 Michigan Health Specialists-Dort Hwy 5494 S. Dort Hwy. Flint, MI 48507 Genesee Katherine Vanderlaan NP 1255605283 Michigan Health Specialists-Linden Rd. 1125 S. Linden Rd Ste 900 Flint, MI 48352 Genesee Cherrell Shells NP 1033410451 Michigan Health Specialists-Robert T. Longway Blvd 2700 Robert T. Longway Blvd, Suite B Flint, MI 48503 Genesee Khalid Ahmed MD 1619965175 Michigan Health Specialists-Robert T. Longway Blvd 2700 Robert T. Longway Blvd, Suite B Flint, MI 48503 Genesee Seif Saeed MD 1598753568 Michigan Health Specialists-Robert T. Longway Blvd 2700 Robert T. Longway Blvd, Suite B Flint, MI 48503 Genesee Faisal Mawri MD 1336346345 Pediatric & Adolescent Advance Care 8143 Saginaw Rd #2 Grand Blanc, MI 48439 Genesee Nuzhat Ali MD 1295897841 Prime Pediatrics & Adolescents 1335 Linden Rd, Flint, MI 48532 Genesee Anna Roth NP 1023264041 The Children's Office 2184 S. Ballenger Hwy Flint, MI 48503 Genesee Ashley Duffield NP 1215300033 The Children's Office 2184 S. Ballenger Hwy Flint, MI 48503 Genesee Duane Allyn DO 1497857650 The Children's Office 2184 S. Ballenger Hwy Flint, MI 48503 Genesee Indu Singala NP 1427429448 The Children's Office 2184 S. Ballenger Hwy Flint, MI 48503 Genesee Joseph Simmert DO 1124120894 The Children's Office 2184 S. Ballenger Hwy Flint, MI 48503 Genesee Kienan Murphy DO 1275635930 The Children's Office 2184 S. Ballenger Hwy Flint, MI 48503 Genesee Paul Chrenka MD 1780621292 The Children's Office 2184 S. Ballenger Hwy Flint, MI 48503 Genesee Cynthia Horning MD 1063514701 TLC Pediatrics 4520 Linden Creek Parkway, Flint MI 48507 Genesee Sarah Sanchez MD 1700988474 TLC Pediatrics 4520 Linden Creek Parkway, Flint MI 48507 Genesee Vijay Naraparju MD 1942400973 Vijay Naroparaju, MD 1375 Flushing Road Flushing, MI 48433 Genesee, Patrick Dale Hawkins NP 1902803877 Kidney Disease and Hypertertension Consultants 2486 Nerredita Suite E Flint, MI 48532 Saginaw, Bay Gogebic Christopher Wells DO 1952626798 Aspirus Grand View Clinic N10565 Grand View Lane Ironwood, MI 49938 Gogebic Jeffrey A. Miller MD 1295843126 Jeffrey A. Miller, MD PC 601 Sunday Lake St Wakefield, MI 49968 Grand Traverse Douglas O'Mara MD 1700803152 Crystal Lake Health Center-Interlochen Clinic 1975 Stirling Dr. Interlochen, MI 49643 Grand Traverse Michael Carroll MD 1346338324 Crystal Lake Health Clinic Chums Corners 4025 Chums Village Dr. Traverse City, MI 49685 Grand Traverse Andrew D. Tursman MD 1215915178 Grand Traverse Childrens Clinic 3537 W. Front Suite G Traverse City, MI 49684 Grand Traverse David S. Olson MD 1497733315 Grand Traverse Childrens Clinic 3537 W. Front Suite G Traverse City, MI 49684 Grand Traverse Jelanie R. Bush MD 1023271780 Grand Traverse Childrens Clinic 3537 W. Front Suite G Traverse City, MI 49684 Grand Traverse Katherine R. Elms MD 1932362670 Grand Traverse Childrens Clinic 3537 W. Front Suite G Traverse City, MI 49684 Grand Traverse Lisa Chimner MD 1053339531 Grand Traverse Childrens Clinic 3537 W. Front Suite G Traverse City, MI 49684 Grand Traverse Robert Sprunk MD 1962480814 Grand Traverse Childrens Clinic 3537 W. Front Suite G Traverse City, MI 49684 Grand Traverse Alicia Classens NP 1710045661 Kid's Creek Children's Clinic 5024 N. Royal Drive Traverse City, MI 49684 Grand Traverse Catherine Carter NP 1336258953 Kid's Creek Children's Clinic 5024 N. Royal Drive Traverse City, MI 49684 Grand Traverse Cynthia Smith MD 1043311731 Kid's Creek Children's Clinic 5024 N. Royal Drive Traverse City, MI 49684 Grand Traverse James Robertson MD 1457357832 Kid's Creek Children's Clinic 5024 N. Royal Drive Traverse City, MI 49684 Grand Traverse Kimberly Hegewald MD 1851379770 Kid's Creek Children's Clinic 5024 N. Royal Drive Traverse City, MI 49684 Grand Traverse Kristina Lishawa MD 1063425205 Kid's Creek Children's Clinic 5024 N. Royal Drive Traverse City, MI 49684 Grand Traverse Rachel Newman MD 1013173392 Kid's Creek Children's Clinic 5024 N. Royal Drive Traverse City, MI 49684 Grand Traverse Stephanie Galdes DO 1396905881 Kid's Creek Children's Clinic 5024 N. Royal Drive Traverse City, MI 49684 Grand Traverse Mara McKinley FNP 1518244912 NW MI Health Services 10767 Traverse Hwy. Traverse City, MI 49684 Grand Traverse Matthew Cody MD 1285754077 NW MI Health Services 10767 Traverse Hwy. Traverse City, MI 49684 Grand Traverse Jennifer Schell DO 1952402653 Traverse Area Pediatrics Adolescent Clinic 4020 W. Royal Dr. Traverse City, MI 49684 Grand Traverse Karla Smith MD 1710088414 Traverse Area Pediatrics Adolescent Clinic 4020 W. Royal Dr. Traverse City, MI 49684 Grand Traverse LuAnn K. Labian MD 1497725410 Traverse Area Pediatrics Adolescent Clinic 4020 W. Royal Dr. Traverse City, MI 49684 Gratiot Greg B. Bechill DO 1073595351 Covenant HealthCare - Alma 1910 Pine Avenue Alma, MI 48801 Gratiot Gregg Stefanek DO 1619913472 Covenant HealthCare - Alma 1910 Pine Avenue Alma, MI 48801 Gratiot Vicki E. Chessin MD 1558302968 Covenant HealthCare - Alma 1910 Pine Avenue Alma, MI 48801 Gratiot Amanda Jakubowski NP 1194118877 Lossio Pediatrics PLLC 245 Warwick Drive Alma 48801 Gratiot Fransisco Lossio MD 1982633988 Lossio Pediatrics PLLC 245 Warwick Drive Alma 48801 Gratiot Hillary Shemes DO 1316268816 Sparrow Medical Group Ithaca 114 N. Main St. Ithaca, MI 48847 Hillsdale Michael Sackman MD 1457387300 Hillsdale Pediatric Clinic 451 Hidden Meadows Drive Ste 200 Hillsdale, MI 49242 Houghton Michael Verive MD 1245278456 Sparrow Medical Group Ithaca 114 N. Main St. Ithaca, MI 48847 Houghton Jeffrey Jacobs MD 1003979501 Superior Pediatrics 324 Fifth St. Calumet, MI 49913 Houghton Colleen Vallad-Hix DO 1033171301 Upper Great Lakes Health Center 500 Campus Dr. Hancock, MI 49930 Houghton Rajanee Sripaipan MD 1124057229 Upper Great Lakes Health Center 500 Campus Dr. Hancock, MI 49930 Houghton Terry Frankovich MD 1073609400 Western Up Dist HD 540 Depot St Hancock 49930 December 8, 2017 Michigan Department of Health and Human Services Page 5 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Huron Clark Jones DO 1811965486 GLBHC-Thumb 876 N. Van Dyke Rd Bad Axe, MI 48413 Huron Tami Dutcher NP 1932454501 GLBHC-Thumb 876 N. Van Dyke Rd Bad Axe, MI 48413 Huron Charles Christensen DO 1518994011 HMC Pediatrics 1060 S. Van Dyke Rd Bad Axe, MI 48413 Huron JoAnn Kapa NP 1285035683 HMC Pediatrics 1060 S. Van Dyke Rd Bad Axe, MI 48413 Huron Yasir Babiker MD 1861685307 Huron Medical Center 1060 S. Van Dyke, Suite 300 Bad Axe, MI 48413 Huron Danielle Brown NP 1679942338 Port Hope Medical Clinic 4255 North Lakeshore Rd. Port Hope, MI 48468 Huron Theresa Guinther DO 132620020 Scheurer Family Medical Center 168 N.Caseville Rd. Pigeon, MI 48755 Ingham Nancy Spates MD 1588642474 Child Health Partners 1515 Lake Lansing Rd. Suite C-2 Lansing, MI 48912 Ingham Poomathi Sadhishkumar MD 1902089295 Child Health Partners 1515 Lake Lansing Rd. Suite C-2 Lansing, MI 48912 Ingham Aimee Leisure-Martins DO 1760746788 Cristo Rey Family Health Clinic 1717 N. High St. Lansing, MI 48910 Ingham Carol Carney NP 1043230154 Cristo Rey Family Health Clinic 1717 N. High St. Lansing, MI 48910 Ingham Linda Hughes NP 1922173103 Cristo Rey Family Health Clinic 1717 N. High St. Lansing, MI 48910 Ingham Erica Still DO 1205147451 Great Lakes Pediatric Associates 3400 Pine Tree Rd. Lansing MI 48911 Ingham Leslie Reynolds MD 1144338443 Great Lakes Pediatric Associates 3400 Pine Tree Rd. Lansing MI 48911 Ingham Olga Napolova MD 1518978345 Ingham Co Child Health Services 5303 S. Cedar St. Lansing, MI 48911-3800 Ingham Hiram Stephen Williams MD 1538191259 Ingham Comm Health Center 5303 S. Cedar PO Box 30161 Lansing, MI 48909-7661 Ingham Melissa Benbow MD 1053564617 Ingham Comm Health Center 5303 S. Cedar PO Box 30161 Lansing, MI 48909-7661 Ingham Don Michael Stiffler MD 1508875949 Ingham Well Child 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Gerard Breitzer DO 1669414116 Ingham Well Child 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Kenneth Stringer DO 1891896940 Ingham Well Child 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Rachel Christensen DO 1992733836 Ingham Well Child 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Jessica Lynn Gengler DO 1629380522 Ingham Well Child-ICHD 5303 S. Cedar St. Lansing, MI 48911-3800 Ingham Jonathan Gold MD 1881602316 Ingham Well Child-ICHD 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Nina Mattarella MD 1881786119 Ingham Well Child-ICHD 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Yakov Sigal MD 1285733162 Ingham Well Child-ICHD 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Arthur Ronan DO 1346283074 Lake Lansing Family Practice 1568 Lake Lansing Rd Lansing, MI 48912 Ingham Jenny Werth NP 1770867657 Lake Lansing Family Practice 1568 Lake Lansing Rd Lansing, MI 48912 Ingham Penny Dabney NP 1144250267 Lake Lansing Family Practice 1568 Lake Lansing Rd Lansing, MI 48912 Ingham Christina Downer DO 1477907350 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham David Leslie DO 1033536529 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham Jesse Zrull DO 1821459454 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham Lauren (Hart) Michels DO 1962884023 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham Madeline Lewis DO 1386635654 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham Mark Garcia DO 1235492182 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham Naila Rashid DO 1992124309 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham Nicole Barrett DO 1497115133 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham Nyebol Madut DO 1760861777 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham Rachel Perry DO 1447601380 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham Sarah Denham DO 1275832784 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham Spencer Tingey DO 1962829374 McLaren Lansing Family Residency 2727 South Pennsylvania Ave Lansing, MI 48910 Ingham Chioma Okeafor MD 1689994220 MSU Pediatrics & Specialty Clinic 1200 E. Michigan Ave. Lansing, MI 48912 Ingham Jane Turner MD 1578660882 MSU Pediatrics & Specialty Clinic 1200 E. Michigan Ave Lansing, MI 48912 Ingham Jonathan Gold MD 1881602316 MSU Pediatrics & Specialty Clinic 1200 E. Michigan Ave Lansing, MI 48912 Ingham Kripa Thakur MD 1386824159 MSU Pediatrics & Specialty Clinic 1200 E. Michigan Ave. Lansing, MI 48912 Ingham Nina Mattarela MD 1881786119 MSU Pediatrics & Specialty Clinic 1200 E. Michigan Ave. Lansing, MI 48912 Ingham Olga Napolova MD 1518978345 MSU Pediatrics & Specialty Clinic 1200 E. Michigan Ave. Lansing, MI 48912 Ingham Sathyan Sudhanthar MD 1689685802 MSU Pediatrics & Specialty Clinic 1200 E. Michigan Ave Lansing, MI 48912 Ingham Yakov Sigal MD 1285733162 MSU Pediatrics & Specialty Clinic 1200 E. Michigan Ave. Lansing, MI 48912 Ingham Kimberly Mitcham DO 1457465155 MSU Pediatrics DeWitt 13750 S. Sedona Parkway Ste 2 Lansing, MI 48906 Ingham Melissa Benbow MD 1053564617 MSU Pediatrics DeWitt 13750 S. Sedona Parkway, Ste 2 Lansing, MI 48906 Ingham Rachel Christenson DO 1992733836 MSU Pediatrics DeWitt 13750 S. Sedona Parkway, Ste 2 Lansing, MI 48906 Ingham Gerard Breitzer DO 1669414116 MSU Pediatrics Okemos 1600 West Grand River Ave Okemos, MI 48864 Ingham Kenneth Stringer DO 1891896940 MSU Pediatrics Okemos 1600 West Grand River Ave Okemos, MI 48864 Ingham Sabrina Dinkha DO 1083877344 MSU Pediatrics Okemos 1600 West Grand River Ave Okemos, MI 48864 December 8, 2017 Michigan Department of Health and Human Services Page 6 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Ingham Abdullah Sharaf Resident MD 1891145850 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Ala Elayyan Resident MD 1295140895 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Allison Carlo Resident DO 1912357146 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Christine Honer Resident DO 1730561366 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Hani Alsaedi Resident MD 1659754968 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Ira Holla Resident MD 1982019345 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Jagraj Brar Resident MD 1073997847 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Jasmine Virk Resident MD 1164872370 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Jordan Daniel Fett Resident MD 1336599273 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Julie Creighton- Contact person Resident DO 1912311853 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Lauren Strady Resident DO 1659721991 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Lindsay Huckabee Resident DO 1275912446 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Marc Zafferani Resident DO 1568812402 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Matthew Carter Resident DO 1023423720 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Mohamed Hani Farhat Resident MD 1043625098 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Rebecca Justin Resident DO 1891100954 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Reem Almomani Resident MD 1730561911 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Richard Fong DO 1063866291 MSU- Sparrow working with Ingham Co HD- Well Child 5303 Cedar St. Lansing, MI 48933 Ingham Samantha Clark Resident DO 1982086492 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Shreya Wachob Resident DO 1497137012 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Stephanie Jarnagin Grondahl Resident DO 1760805352 MSU- Sparrow working with Ingham Co HD- Well Child 1215 E. Michigan Ave. Lansing, MI Ingham Dawn Springer MD 1558310771 SMG Mason 230 Temple Street, PO Box 39 Mason, MI 48854 Ingham Abigail Richeson DO 1427435320 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Ajeet Sidhu MD 1932515772 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Amir Koldorf DO 1790136893 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Amy Odom DO 1639114739 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Anita Bell DO 1326494907 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Anthony Agrusa DO 1528419199 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Brooke Lemmen DO 1487864245 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham David Sabbagh MD 1295183747 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Erik Colegrove MD 1467715201 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Garry Mann MD 1912359126 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham George Chou DO 1861841660 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham George Smith MD 1891884458 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Harmeet Dhaliwal MD 1831572106 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham James Olson MD 1336237221 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Jan Liv MD 1164805685 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Jennifer Edwards-Johnson DO 1083972434 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Joseph Nettleman MD 1578942975 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Julie Phillips MD 1609995000 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Justin Rutt DO 1578950804 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Katie Ryan MD 1255745857 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Kelly Gries DO 1851702518 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Kenneth Thompson MD 1376649095 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Kyle Ungvarsky MD 1174937916 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Lauren Anastos DO 1083064125 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Laurie Rozek DO 1245644392 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Mark Kidwell DO 1366892150 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Melissa Gates DO 1417362039 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Michelle Loubert DO 1245688514 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Olayemi Jafojo MD 1760834337 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Randy Pearson MD 1770687998 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Ravinder Dhillon MD 1952783847 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Robert Albers DO 1427462639 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 December 8, 2017 Michigan Department of Health and Human Services Page 7 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Ingham Robert Darios MD 1548366818 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Rohin Khanna MD 1619357068 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Rosemary Roper DO 1275893935 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Sarah Hagle MD 1235544081 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Shirin Clark DO 1073589040 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Stella Zhang DO 1760831580 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Syeeda Alam DO 1144617564 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Valerie Johnson DO 1225136187 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Veronica Arbuckle-Bernstein MD 1760830236 Sparrow Family Medicine Residency 1200 E. Michigan Ave., Suite 245C Lansing, MI 48912 Ingham Camy Chapin MD 1992993117 Well Child Clinic 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Danielle T. Miller Physician 1598965295 Well Child Clinic 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Gohar Ashraf MD 1699937771 Well Child Clinic 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Guitar Hanna DO 1457513046 Well Child Clinic 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Madhulika A. Kulkarni MD 1043461015 Well Child Clinic 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Melissa Wylie DO 1043419674 Well Child Clinic 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Robert Root DO 1043472665 Well Child Clinic 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Ruth Worthington DO 1437184207 Well Child Clinic 545 W. Fee Hall E Lansing 48824 Ingham Santokh S. Dhillon MD 1225151236 Well Child Clinic 5400 Mall Dr. West, Apt 3107 Lansing, MI 48917 Ingham Sumit Dang MD 1356505689 Well Child Clinic 901 E. Mt. Hope Rd. Lansing, MI 48910 Ingham Teasha Frattarelli DO 1932394483 Well Child Clinic 414 Cherry St. Dewitt, MI 48820 Ionia John Hildebrandt MD 1598751968 Ionia Associates LLC, DBA Ionia Family Practice 330 Lovell Street Ionia, MI 48846 Ionia Bhagya Venkatesh MD 1679882005 SMG Portland 9715 E. Grand River Ave., Portland MI 48875 Ionia Christopher Ruthruff MD 1831144179 Sparrow Medical Group Ionia- Family Health Care 550 E. Washington 2nd Floor Ionia, MI 48846 Ionia Gregory Lawson MD 1598077216 Sparrow Medical Group Ionia- Family Health Care 550 E. Washington 2nd Floor Ionia, MI 48846 Ionia Lauren Smith MD 1649290685 Sparrow Medical Group Ionia- Family Health Care 550 E. Washington 2nd Floor Ionia, MI 48846 Ionia Lynn Toaz DO 1912924895 Sparrow Medical Group Ionia- Family Health Care 550 E. Washington 2nd Floor Ionia, MI 48846 Ionia Rose Hunter MD 1760431407 Sparrow Medical Group Ionia- Family Health Care 550 E. Washington 2nd Floor Ionia, MI 48846 Ionia Vishal Saini MD 1477866390 Sparrow Medical Group Ionia- Family Health Care 550 E. Washington 2nd Floor Ionia, MI 48846 Ionia Amy B. Curry DO 1649438748 Spectrum Health-Belding Family Medicine 1227 W. State Street Belding, MI 48809 Ionia Nicole Parrott NP 1396096004 Spectrum Health-Belding Family Medicine 1227 W. State Street Belding, MI 48809 Ionia, Ingham Dr. Lowhim MD, MPH 1255426326 Ionia Co HD 175 E. Adams St. Ionia, MI 48846 Iosco Dr. Jo Studley MD 1891709960 St. Joseph Pediatrics 325 MS5 Tawas 48763 Isabella Robert Graham DO, MPH 1598754731 Central Mi Dist Health Dept 2012 E. Preston Ave Mt Pleasant, MI 48858 Isabella Rumana Barodawalla MD 1144342320 Children's Health Care 709 S. Adams St. Mt. Pleasant, MI 48858 Isabella Constanza Fox MD 1831157734 Fox Pediatrics 1205 South Mission Point Street, Suite 4, Mt Pleasant, MI Isabella Karen Rathmann MD 1760785562 Medical Arts Pediatrics 1201 South Drive Suite 341 Mt. Pleasant MI 48858 Isabella Steven Walvisch MD 1497792238 Medical Arts Pediatrics 1201 South Drive Suite 341 Mt. Pleasant MI 48858 Isabella Bhekumusa Msibi DO 1649212952 Pleasant Pediatrics 1970 Ashland Drive Mt. Pleasant Mi 48858 Jackson Souha Hakim MD 1699798249 Pediatric Center of Jackson 1418 E. Michigan Ave. Jackson, MI 49202 Kalamazoo Colleen Dodich MD 1699989384 Bronson Rambling Road Pediatrics-Kalamazoo 5629 Stadium Dr. Suite A Kalamazoo, MI 49009 Kalamazoo Emma Lister MD 1487827754 Bronson Rambling Road Pediatrics-Kalamazoo 5629 Stadium Dr. Suite A Kalamazoo, MI 49009 Kalamazoo Jeannette Gaggino MD 1093785560 Bronson Rambling Road Pediatrics-Kalamazoo 5629 Stadium Dr. Suite A Kalamazoo, MI 49009 Kalamazoo Kelli Dodson-Hunt DO 1851594659 Bronson Rambling Road Pediatrics-Kalamazoo 5629 Stadium Dr. Suite A Kalamazoo, MI 49009 Kalamazoo Kristi Fifelski NP 1609846252 Bronson Rambling Road Pediatrics-Kalamazoo 5629 Stadium Dr. Suite A Kalamazoo, MI 49009 Kalamazoo Lisa Nagler MD 1093785644 Bronson Rambling Road Pediatrics-Kalamazoo 5629 Stadium Dr. Suite A Kalamazoo, MI 49009 Kalamazoo Michelle Jepsen NP 1336119809 Bronson Rambling Road Pediatrics-Kalamazoo 5629 Stadium Dr. Suite A Kalamazoo, MI 49009 Kalamazoo Padma Reddy MD 1154391621 Bronson Rambling Road Pediatrics-Kalamazoo 5629 Stadium Dr. Suite A Kalamazoo, MI 49009 Kalamazoo Randall Dyk MD 1033199674 Bronson Rambling Road Pediatrics-Kalamazoo 5629 Stadium Dr. Suite A Kalamazoo, MI 49009 Kalamazoo Christopher Goodwin MD 1558306944 Bronson Rambling Road Pediatrics-Portage 2680 W Centre Ave. Portage, MI 49024 Kalamazoo Jamie Harden DO 1831458272 Bronson Rambling Road Pediatrics-Portage 2680 W Centre Ave. Portage, MI 49024 Kalamazoo Julie Elias MD 1215078142 Bronson Rambling Road Pediatrics-Portage 2680 W Centre Ave. Portage, MI 49024 Kalamazoo Katherine Harig NP 1275887051 Bronson Rambling Road Pediatrics-Portage 2680 W Centre Ave. Portage, MI 49024 Kalamazoo Mary Schira NP 1902886518 Bronson Rambling Road Pediatrics-Portage 2680 W Centre Ave. Portage, MI 49024 Kalamazoo Megan Sikkema DO 1629337068 Bronson Rambling Road Pediatrics-Portage 2680 W Centre Ave. Portage, MI 49024 December 8, 2017 Michigan Department of Health and Human Services Page 8 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Kalamazoo Sara Ehlke-Bejcek MD 1023089604 Bronson Rambling Road Pediatrics-Portage 2680 W Centre Ave. Portage, MI 49024 Kalamazoo David Beard FNP-C 1679989370 Family Health Center of Kalamazoo 117 W. Paterson St. Kalamazoo, MI 49007 Kalamazoo Dr. Colette Gushurst MD 1801865811 MSU- Kalamazoo Center for Medical Studies 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Ann P. Sheehan DNP, RN, 1639177983 Pediatrics PC 670 Mall Dr. Portage, MI 49024 CPNP Kalamazoo Davis Ohmart MD 1437129095 Pediatrics PC 670 Mall Dr. Portage, MI 49024 Kalamazoo Mark A. Blazek MD 1649240292 Pediatrics PC 670 Mall Dr. Portage, MI 49024 Kalamazoo Aimee Wagnitz Simpson MD 1386848182 ProMed Pediatrics- Borgess 8001 Angling Rd Portage, MI 49024 Kalamazoo Ashley Diehl MD 1316230865 ProMed Pediatrics- Borgess 8450 N 32nd St Richland, MI 49083 Kalamazoo Evan House Pelc DO 1811286966 ProMed Pediatrics- Borgess 8001 Angling Rd Portage, MI 49024 Kalamazoo Genevieve Bastos CPNP 1902843774 ProMed Pediatrics- Borgess 8001 Angling Rd Portage, MI 49024 Kalamazoo John Spitzer MD 1164530077 ProMed Pediatrics- Borgess 8001 Angling Rd Portage, MI 49024 Kalamazoo Linda Garrison MD 1023124799 ProMed Pediatrics- Borgess 8001 Angling Rd Portage, MI 49024 Kalamazoo Megan Foley NP 1831335124 ProMed Pediatrics- Borgess 8450 N 32nd St Richland, MI 49083 Kalamazoo Melissa Ann Reffitt CPNP 1104934488 ProMed Pediatrics- Borgess 8001 Angling Rd Portage, MI 49024 Kalamazoo Sandhya Sood-McMillen MD 1215946199 ProMed Pediatrics- Borgess 8001 Angling Rd Portage, MI 49024 Kalamazoo Anthony Vanes MD 1154300366 Trestlewood Pediatrics 5082 Lovers Lane Portage, MI 49002 Kalamazoo Gail Brown MD 1407835614 Trestlewood Pediatrics 5082 Lovers Lane Portage, MI 49002 Kalamazoo Rebekah Lampart DO 1881897213 Trestlewood Pediatrics 5082 Lovers Lane Portage, MI 49002 Kalamazoo Robert Page MD 1710966783 Trestlewood Pediatrics 5082 Lovers Lane Portage, MI 49002 Kalamazoo Stephanie Somers MD 1972582302 Trestlewood Pediatrics 5082 Lovers Lane Portage, MI 49002 Kalamazoo Alexander Witte MD 1932512779 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Allan Wilke MD 1366404097 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Amanda Springer MD 1144660838 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Charlotte Moriarty MD 1538452966 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Emily Clare-Showerman Smith DO 1043655012 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Ferris Alkazir MD 1053757849 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Glenn Dregansky DO 1134128093 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Ibad Farooqui MD 1427499318 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Imran Shafqat MD 1336404540 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Jane Hanneken MD 1780652834 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Julius Ramirez MD 1548520638 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Kimberly Gygi DO 1356600787 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Kristi VanDerKolk MD 1245469428 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Latifa Pacheco DO 1366853640 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Lauren Piper DO 1073552279 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Nicole Akers MD 1790071165 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Rebekah Costello DO 1326452921 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Robert Baker MD 1689642803 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Sneh Patel MD 1447511043 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Sonia Haque MD 1952663171 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Steve Pollens MD 1790755270 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Sukhpreet Singh MD 1336401124 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Susan Jevert DO 1053756510 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Wesley Eichorn DO 1457762734 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Zachary Koehn DO 1164837977 Western Michigan Univ School of Med 1000 Oakland Dr. Kalamazoo 49008 Kalamazoo Aisha Goraya MD 1659723872 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Alison Radigan MD 1770958936 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Allan Wilke MD 1366404097 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Aydin Tavakoli MD 1073929600 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Ferris Alkazir MD 1053757849 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Jamie McCartney MD 1982017265 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo John Cochrane MD Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Joshua Fainsod MD 1427407006 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 December 8, 2017 Michigan Department of Health and Human Services Page 9 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Kalamazoo Justin Di Donato MD 1548612815 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Kristi VanDer Kolk MD 1245469428 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Larry Mann DO 1497133714 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Latifa Pacheco DO 1366853640 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Lauren Piper DO 1073552279 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Lauren Vocke DO 1396192472 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Lindsey Henderson Drevecky MD 1609215151 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Manpreet Narwal MD 1609257658 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Mehmiya Raghid MD 1174971170 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Narinder Clair MD 1629459672 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Nicole Akers MD 1790071165 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Nithin Natwa MD 1932580230 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Nithin Natwa MD 1932580230 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Oro Enaohwo MD 1093197311 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Shaena Freeman MD 1023490943 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Stephanie Witte MD 1558711739 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Susan Jevert DO 1053756510 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Uzair Munshey MD 1841671146 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Varinder Sidhu MD 1639599947 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Wesley Eichorn DO 1457762734 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Zhen Geng MD 1154779007 Western Michigan University Family Residency 117 W. Paterson Kalamazoo, MI 49007 Kalamazoo Alec Wilson MD 1780064691 Western Michigan University MED/PEDS Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Program Kalamazoo Cayleigh Blumrick MD 1851740807 Western Michigan University MED/PEDS Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Program Kalamazoo Claire Liepmann MD 1992184378 Western Michigan University MED/PEDS Residency 1000 Oakland Drive Kalamazoo, MI 49008 Program Kalamazoo Elizabeth Doherty MD 1093036790 Western Michigan University MED/PEDS Residency 1000 Oakland Drive Kalamazoo, MI 49008 Program Kalamazoo Emily Cordes DO 1770961096 Western Michigan University MED/PEDS Residency 1000 Oakland Drive Kalamazoo, MI 49008 Program Kalamazoo Emily Goerl DO 1598145401 Western Michigan University MED/PEDS Residency 1000 Oakland Drive Kalamazoo, MI 49008 Program Kalamazoo Jason Lam DO 1861837338 Western Michigan University MED/PEDS Residency 1000 Oakland Drive Kalamazoo, MI 49008 Program Kalamazoo Jayne Barr MD 1053340810 Western Michigan University MED/PEDS Residency 1000 Oakland Drive Kalamazoo, MI 49008 Program Kalamazoo Matthew Siuba DO 1083059182 Western Michigan University MED/PEDS Residency 1000 Oakland Drive Kalamazoo, MI 49008 Program Kalamazoo Patrick Staso MD 1750762050 Western Michigan University MED/PEDS Residency 1000 Oakland Drive Kalamazoo, MI 49008 Program Kalamazoo Rheanne Maravelas MD 1629429758 Western Michigan University MED/PEDS Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Program Kalamazoo Rose Archemetre MD 1922455997 Western Michigan University MED/PEDS Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Program Kalamazoo Theotonius Gomes DO 1205276664 Western Michigan University MED/PEDS Residency 1000 Oakland Drive Kalamazoo, MI 49008 Program Kalamazoo Thomas Melgar MD 1154390334 Western Michigan University MED/PEDS Residency 1000 Oakland Drive Kalamazoo, MI 49008 Program Kalamazoo Wylie deVera MD 1033307376 Western Michigan University MED/PEDS Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Program Kalamazoo Zachary Rich MD 1790133643 Western Michigan University MED/PEDS Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Program Kalamazoo Alex Mast DO 1679920755 Western Michigan University Pediatric Residency 1000 Oakland Dr. Kalamazoo, MI 49008 December 8, 2017 Michigan Department of Health and Human Services Page 10 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Kalamazoo Anju Patel MD 1407260110 Western Michigan University Pediatric Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Kalamazoo Cailly Howell MD 1760839849 Western Michigan University Pediatric Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Kalamazoo Garrett Koon DO 1366821746 Western Michigan University Pediatric Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Kalamazoo Jasmine Alsukhon MD 1710335716 Western Michigan University Pediatric Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Kalamazoo Katie Udenberg DO 1699121384 Western Michigan University Pediatric Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Kalamazoo Priscilla Woodhams MD 1972512960 Western Michigan University Pediatric Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Kalamazoo Sabrina Huq DO 1083062087 Western Michigan University Pediatric Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Kalamazoo Skye Lu DO 1609224559 Western Michigan University Pediatric Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Kalamazoo Yamini Kuchipudi MD 1013327394 Western Michigan University Pediatric Residency 1000 Oakland Dr. Kalamazoo, MI 49008 Kalamazoo Kristine Maria Gibson MD 1972573525 WMed Pediatric Clinic 1000 Oakland Dr. Kalamazoo, MI 49008 Kalamazoo Kristine Maria Gibson MD 1972573525 WMed Pediatric Clinic 1000 Oakland Dr. Kalamazoo, MI 49008 Kalamazoo, Van Kathleen L. Lemmen MD 1801867106 Pediatrics PC 670 Mall Dr. Portage, MI 49024 Buren, Allegan, St. Joseph, Barry, Calhoun, Berrien Kalamazoo, Van Sandra Wiederhold MD 1275643223 Pediatrics PC 670 Mall Dr. Portage, MI 49024 Buren, Allegan, St. Joseph, Barry, Calhoun, Berrien Kent Scott Carlson DO 1750386199 Family Care Center 1525 East Beltline Suite 101 Grand Rapids, MI 49525 Kent Tarajo Hanrahan MD 1295256063 GRMEP 18380 112th Ave Nunica, MI 49448 Kent Tarajo Hanrahan MD 1295256063 GRMEP 18380 112th Ave Nunica, MI 49448 Kent Carol Rossman NP 1265642532 GVSU Family Health Center 72 Sheldon Blvd Grand Rapids, 49503 Kent Donna DeMann FNP-BC 1801848189 GVSU Family Health Center 72 Sheldon Blvd, SE Grand Rapids, MI 49503 Kent Erin Baar NP 1417181397 GVSU Family Health Center 72 Sheldon Blvd Grand Rapids, 49503 Kent Jamie Allen NP 1225078520 GVSU Family Health Center 72 Sheldon Blvd Grand Rapids, 49503 Kent Jamie Lamers FNP-BC 1134484751 GVSU Family Health Center 72 Sheldon Blvd, SE Grand Rapids, MI 49503 Kent Kimberly Fenbert-Contact DNP, CPNP 1811995228 GVSU Family Health Center 72 Sheldon Blvd, SE Grand Rapids, MI 49503 Kent Aaron Tolan MD 1881909596 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503

Kent Abby St Jacques MD 1487940946 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503

Kent Abeba Berhane MD 1033436761 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503

Kent Adam Robinson MD 1326300682 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Aileen Aldrich MD 1184063869 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Aliese Sarkissian MD 1255693172 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Allie Maffit MD 1639434376 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Amanda Rudert MD 1811336506 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Amy Chang MD 1306108329 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Andre Hollingsworth MD 1801184247 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Angela Pham MD 1083993901 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Angela Thompson-Busch MD 1952384372 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Anjan Chakrabarty MD 1902111412 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Annette George MD 1275972952 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Ashley Barcroft MD 1215376512 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Brian LeCleir MD 1417211301 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Caitlin Mlynarek DO 1376924340 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Candace Johnson MD 1417242553 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Cara Zokoe MD 1093154783 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Cecelia Calhoun MD 1447545652 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 December 8, 2017 Michigan Department of Health and Human Services Page 11 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Kent Chelsea Cunliffe MD 1245542133 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Cheryl Kuz MD 1447230107 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Chloe Mallacker MD 1811336597 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Chris Amos MD 1386931319 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Danny Gil MD 1629417316 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Derrick Hokeman MD 1821385683 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Elizabeth Parker MD 1720427412 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Hanna Jaworski MD 1588878631 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Jane Lee MD 1366881047 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Jason Thomas MD 1093154775 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Jennata Francis MD 1124381462 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Jennifer Ruprich MD 1386907491 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Jessica Pedersen MD 1992144687 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Joel Veldhouse MD 1659685741 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Jon Felt MD 1699060665 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Jonathan VanderSilk MD 1477815850 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Justine Bunka MD 1720341951 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Kahlie Hauser MD 1639518319 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Karen Sue VanderLaan MD 1447230891 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Katherine Conliffe MD 1053606103 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Katherine Patrick MD 1649533092 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Kimberly Spronk MD 1528320546 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Kristen Jacob MD 1811250368 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Kyle Sloan MD 1245526524 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Lacey Althausen MD 1548609233 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Lana Gagin MD 1669693487 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Laura Most MD 1437446481 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Lisa Barry MD 1902245699 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Lisa Lowery MD 1235119975 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Luke VandeZande MD 1497194799 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Mary Avendt MD 1891081972 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Maysee Salleva MD 1326336777 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Melissa Huang MD 1538454442 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Melissa Schneider MD 1093000259 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Miranda L. Perosky MD 1942597729 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Natasha Holt MD 1306286059 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Noelle Morey MD 1710249750 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Nwanzu Ndika MD 1063893030 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Phillip Paras MD 1003016064 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Randall Leja MD 1891058624 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Renee Barrett MD 1063775484 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Sara VandenBranden MD 1437414133 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Shawna Pierce MD 1700149929 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Stacie Adams MD 1679869143 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Stephanie Klein MD 1548609225 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Stephen Hinkin MD 1437447851 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Ted Kelbel MD 1326333444 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Timothy Conroy MD 1932189651 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Vani Pinnamaneni MD 1679912976 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent William Stratbucker MD 1002883281 Helen DeVos Children's Hosp/Academic General Ped Clinic 330 Barclay Suite 300 Grand Rapids, MI 49503 Kent Benjamin Willenbring MD 1902160385 Mercy Health Browning Claytor Health Center 1246 Madison Ave Southeast Grand Rapids, MI 49507 Kent Brianna Bender MD 1548587231 Mercy Health Browning Claytor Health Center 1246 Madison Ave Southeast Grand Rapids, MI 49507 Kent Gabriel Williams MD 1801024872 Mercy Health Browning Claytor Health Center 1246 Madison Ave Southeast Grand Rapids, MI 49507 Kent Karen Kennedy MD 1912926486 Mercy Health Browning Claytor Health Center 1246 Madison Ave Southeast Grand Rapids, MI 49507 December 8, 2017 Michigan Department of Health and Human Services Page 12 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Kent MaryBeth Adyniec NP 1720006562 Mercy Health Browning Claytor Health Center 1246 Madison Ave Southeast Grand Rapids, MI 49507 Kent Thomas Sanchez NP 1770632952 Mercy Health Browning Claytor Health Center 1246 Madison Ave Southeast Grand Rapids, MI 49507 Kent Clara VanderWeide NP 1558744797 Mercy Health Clinica Santa Maria 730 Grandville Ave SW Grand Rapids, MI 49503 Kent David Jasperse MD 1609119544 Mercy Health Clinica Santa Maria 730 Grandville Ave SW Grand Rapids, MI 49503 Kent Gerard Rudy MD 1598031940 Mercy Health Clinica Santa Maria 730 Grandville Ave SW Grand Rapids, MI 49503 Kent Lee Heeringa MD 1972869048 Mercy Health Clinica Santa Maria 730 Grandville Ave SW Grand Rapids, MI 49503 Kent Patricia Van Baren MD 1407809726 Mercy Health Clinica Santa Maria 730 Grandville Ave SW Grand Rapids, MI 49503 Kent Adnaan Edun MD 1609398882 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Allison Cook MD 1376993428 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Amanda Truer MD 1154772663 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Anna Friend MD 1902287972 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Ariana Lockstadt MD 1992188684 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Barbara Grzegorczyk MD 1922482413 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Barbara Stanford MD 1063438844 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Ben Davidson MD 1215341458 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Caleb Walters MD 1427409937 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Camille Riddering MD 1306250543 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Emily Schipper MD 1184074239 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Iain Charnley MD 147680439 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Jacob Turnbull DO 1962853473 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent James Griffith MD 1306238274 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Jana Baatenburg MD 1720438872 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Jane Visser NP 1518913961 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Jared Langerak MD 1497169635 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Jarrad Utter MD 1942614185 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Jean Thomas MD 1265488688 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Jeffrey Chamberlain MD 1790905214 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent John Carr MD 1821471509 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent John Cavacece DO 1093768244 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent John vanSchagen MD 1144276411 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Jonathon Creary MD 1730531849 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Justin Blaauwendraat MD 1902289697 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Kathryn Kozminski MD 1457732422 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Lara Baatenburg MD 1336590843 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Maha Ayashi MD 1134257694 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Marc Arenas MD 1871908970 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Marc Travis MD 1497708366 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Mario Cesario MD 1124093679 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Matthew Falkiewicz MD 1447631411 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Michael Bishop MD 1316920614 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Michael Delaney MD 1174905905 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Michael Lacroce MD 1457767782 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Mitchell Sydloski MD 1760896906 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Nicholas Blank MD 1275914244 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Nirali Bora MD 1811000953 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Rajeevan Jesudas MD 1366850737 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Samantha McPharlin MD 1386165157 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Samer Haj-Bakri MD 1487038139 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Shawn Reidy MD 1013438886 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Simone Gentles MD 1306253000 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Steven Ashmead MD 1710931704 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Tarajo Hanrahan MD 1295256063 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Thomas Hilts DO 1306899935 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Timothy Dickinson MD 1316928161 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 December 8, 2017 Michigan Department of Health and Human Services Page 13 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Kent Timothy Jelsema MD 1871944397 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent William Ahrens MD 1417994088 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent William Mi MD 1861948895 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Yu-Chen Liu MD 1740664234 Mercy Health Family Med. Residency 300 Lafayette SE suite 4000 Grand Rapids, MI 49503 Kent Karri MacMillan DO 1467865188 Mercy Health Physician Partners 200 Lafayette Ste 4200 Grand Rapids, MI 49503 Kent Catherine Benitez MD 1487732186 Mercy Health Physician Partners - Downtown 245 Cherry Street SE Grand Rapids, MI 49503 Kent Esmerelda Cadena MD 1467405605 Mercy Health Physician Partners - Downtown 245 Cherry Street SE Grand Rapids, MI 49503 Kent Sheila Wang MD 1225262967 Mercy Health Physician Partners - Downtown 245 Cherry Street SE Grand Rapids, MI 49503 Kent Brian Buckler MD 1154344398 Mercy Health Physician Partners-East Beltline 1471 E. Beltline Ave NE, Suite 201 Grand Rapids, MI 49525 Kent Christian Vanderkaay MD 1730493792 Mercy Health Physician Partners-East Beltline 1471 E. Beltline Ave NE, Suite 201 Grand Rapids, MI 49525 Kent Frigga Jacobs MD 1508153263 Mercy Health Physician Partners-East Beltline 1471 E. Beltline Ave NE, Suite 201 Grand Rapids, MI 49525 Kent Jill Bultje MD 1568414241 Mercy Health Physician Partners-East Beltline 1471 E. Beltline Ave NE, Suite 201 Grand Rapids, MI 49525 Kent Melanie Ranta NP 1316990757 Mercy Health Physician Partners-East Beltline 1471 E. Beltline Ave NE, Suite 201 Grand Rapids, MI 49525 Kent Sarah Rodriguez MD 1194089672 Mercy Health Physician Partners-East Beltline 1471 E. Beltline Ave NE, Suite 201 Grand Rapids, MI 49525 Kent John H. Schneider MD 1588689210 Mercy Health Sparta Family Health Center 475 S. State Street Sparta, MI 49345 Lapeer Katelyn Bailey NP 1700262722 Lapeer Pediatrics 1083 Suncrest Dr. Suite A Lapeer, MI 48446 Lapeer Mohamed Harastani MD 1619968922 Lapeer Pediatrics 1083 Suncrest Dr. Suite A Lapeer, MI 48446 Lenawee Per Lamont Okey MD 1518059765 Family Medical Center-Adrian 1200 N. Main Street Adrian, MI 49221 Lenawee William DeMots MD 1992791453 Family Medical Center-Adrian 1200 N. Main Street Adrian, MI 49221 Lenawee Cara Daniel MD 1104831676 Health Specialists of Lenawee PC PO Box 130 Tecumseh, MI 49286 Lenawee Christine Sanborn CPNP 1174705750 Health Specialists of Lenawee PC 6869 Occidental Hwy Tecumseh, MI 49286 Lenawee Tracy Brooke Gelske-Trelour MD 1134245442 Health Specialists of Lenawee PC 6869 Occidental Hwy Tecumseh, MI 49286 Lenawee Asunion Luz MD 1497758650 Pediatric Center Inc. - Adrian 770 Riverside Ave Adrian, MI 48117 Lenawee Helen Jakstas NP 1326148479 Pediatric Center Inc. - Adrian 770 Riverside Ave Adrian, MI 48117 Lenawee Laura L. Bell NP 1740366616 Pediatric Center Inc. - Adrian 770 Riverside Ave Adrian, MI 48117 Lenawee Dr. Kamala Vanaharam MD 1336104470 Pediatric Office 7828 22 Mile Rd Utica 48317 Livingston Nicole Hawkins NP 1659503696 Blue Sky Health 138 W. Highland Road Ste 950 Howell, MI 48843 Livingston Melissa Zarow DO 1891743324 IHA Livingston Pediatrics 2305 Genoa Business Park Dr. Suite 240 Brighton, MI 48114 Livingston Bethany Hall MD 1235243932 IHA-Livingston Pediatrics 2305 Genoa Business Park Drive, Ste. 240 Brighton, MI 48114 Livingston Christopher Kottke MD 1053425777 IHA-Livingston Pediatrics 2305 Genoa Business Park Drive, Ste. 240 Brighton, MI 48114 Livingston Jessica Huhn MD 1710072483 IHA-Livingston Pediatrics 2305 Genoa Business Park Drive, Ste. 240 Brighton, MI 48114 Livingston Kristen Upton NP 1073717922 IHA-Livingston Pediatrics 2305 Genoa Business Park Drive, Ste. 240 Brighton, MI 48114 Livingston Maria DeLeon DO 1851557433- IL IHA-Livingston Pediatrics 2305 Genoa Business Park Drive, Ste. 240 Brighton, MI 48114 Livingston Melanie Klenk NP 1275686099 IHA-Livingston Pediatrics 2305 Genoa Business Park Drive, Ste. 240 Brighton, MI 48114 Livingston Melissa Zarow DO 1891743324 IHA-Livingston Pediatrics 2305 Genoa Business Park Drive, Ste. 240 Brighton, MI 48114 Livingston Aimee Pollak MD 1205009974 IHA-Livingston Peds 2305 Genoa Business Park Dr, ste240 Brighton, MI 48114 Livingston Julie Byrne CNP 1790119972 IHA-Livingston Peds 2305 Genoa Business Park Dr, Ste 200 Brighton, MI 48114 Livingston Mary Khunger MD 1164491726 IHA-Livingston Peds 2305 Genoa Business Park Dr, ste240 Brighton, MI 48114 Livingston Stacey O'Connnor DO 1457329831 IHA-Livingston Peds 2305 Genoa Business Park Dr, Ste 200 Brighton, MI 48114 Livingston Abhilash Kotte MD 1467807735 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Adam Frimodig DO 1316381387 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Anas Souqiyyeh MD 1508286667 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Angelo Savino MD 1235557877 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Benjamin Gilbert DO 1033571302 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Chukwudi Mbagwu MD 1881097442 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Elizabeth Karaska DO 1568859429 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Fyzah Qureshi MD 1710349766 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Jacquelynn Hatch DO 1407299647 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Jami Matthews DO 1225455785 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Kate Szymanski DO 1871954206 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Kathryn DeGrande DO 1164883633 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Kyleigh Naismith DO 1396163390 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Mark Langlois MD 1295154656 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Michael Bradburn DO 1255746731 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 December 8, 2017 Michigan Department of Health and Human Services Page 14 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Livingston Mohsin Reza MD 1043604135 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Rohan Shah MD 1811314792 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Syeda Asad MD 1669834453 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Wisam Khalil MD 1407206790 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Zoe Foster MD 1477520963 Livingston Family Medicine Residency 7575 Grand River Dr. Brighton, MI 48114 Livingston Bipin Desai MD 1669412599 Livingston Pediatric Center 136 Kissane Ave Brighton, MI 48116 Livingston April Ping MD 1073527255 Pediatric Associates of Livingston 8548 W. Grand River Brighton, MI 48116 Livingston Daniel Gisslen MD 1679607287 Pediatric Associates of Livingston 8548 W. Grand River Brighton, MI 48116 Livingston Penny S. Baumeier DO 1144386624 Pediatric Associates of Livingston 8548 W. Grand River Brighton, MI 48116 Livingston Felicia Tsaur MD 1043570039 U of M Brighton Health Center 8001 Challis Road Brighton, MI 49116 Livingston Cheryl Wickham MD 1285687939 University of Michigan 8695 Tamarack Dr. Brighton, MI 48116 Livingston David Wallace MD 1437478385 Uof M Med-Brighton Health Center 8001 Challis Road Brighton, MI 49116 Livingston Jennifer Glamann MD 1194952655 Uof M Med-Brighton Health Center 8001 Challis Road Brighton, MI 49116 Livingston Julia Madison-Williams MD 1033125208 Uof M Med-Brighton Health Center 8001 Challis Road Brighton, MI 49116 Livingston Lynn Gessner MD 1780608943 Uof M Med-Brighton Health Center 8001 Challis Road Brighton, MI 49116 Livingston Shanti Rao MD 1326054594 Uof M Med-Brighton Health Center 8001 Challis Road Brighton, MI 49116 Livingston Stephanie Goodson MD 1639188642 Uof M Med-Brighton Health Center 8001 Challis Road Brighton, MI 49116 Livingston Susan Engert MD 1427163856 Uof M Med-Brighton Health Center 8001 Challis Road Brighton, MI 49116 Livingston Cheryl Wickham MD 1285687939 UofM Med-Howell Pediatrics 711 Byron Rd Howell, MI 48843 Livingston Cynthia Ruiz MD 1831105006 UofM Med-Howell Pediatrics 711 Byron Rd Howell, MI 48843 Livingston Lauran Reed MD 1144480872 UofM Med-Howell Pediatrics 711 Byron Rd Howell, MI 48843 Luce, Mackinac, Dr. James Terrian MD 1790908861 LMAS District Health Department 14140 Hamiton Lake Rd Newberry, MI 49868 Alger, Schoolcraft Mackinac Christopher Gunnell MD 1932142262 Mackinac Straits Health Systems-St. Ignace 1140 N. State Street St. Ignace, MI 49781 Macomb Durdana Rehman MD 1558399808 Durdana Rehman MD PC 35450 Dequindre Rd, Suite # 105 Sterling Heights, MI 48310 Macomb Mary Burton Brooks MD Henry Ford- Sterling Heights 3500 15 Mile Rd Sterling Heights, MI 48310 Macomb Lani Devaney DO 1659305787 HFHS-Sterling Heights Pediatrics 3500 15 Mile Rd. Sterling Heights, MI 48313 Macomb Sybil Rodriguez MD 1740337559 HFHS-Sterling Heights Pediatrics 3500 15 Mile Rd. Sterling Heights, MI 48313 Macomb Usha Batra MD 1245387042 HFHS-Sterling Heights Pediatrics 3500 15 Mile Rd. Sterling Heights, MI 48313 Macomb Hikmat Gogue MD 1821066697 Hikmat Gogue MD PC 39242 Dequindre Road, Suite 101 Sterling Heights, MI 48310 Macomb Paul Gogue MD 1104172212 Hikmat Gogue MD PC 39242 Dequindre Road, Suite 101 Sterling Heights, MI 48310 Macomb Rekha Shah MD 1215973086 Hollywood Pediatric Clinic 18811 East Ten Mile Road Roseville, MI 48066 Macomb Husain Arastu MD 1528017555 Husain Arastu MD, PC 11446 E. 13 Mile Rd. Suite B Warren, MI 48093 Macomb Antoun Oska MD 1518912013 Macomb Pedatric Associates, PC-Warren 29703 Hoover Rd #C Warren, MI 48088 Macomb Ashraf Berry MD 1225083967 Macomb Pedatric Associates, PC-Warren 29703 Hoover Rd #C Warren, MI 48088 Macomb Banumathy Subramanian MD 1144238742 Macomb Pedatric Associates, PC-Warren 29703 Hoover Rd #C Warren, MI 48088 Macomb Laurel Gorham CPNP 1356360499 Mecosta Health Services 650 Linden Suite 1 Big Rapids 49307 Macomb Mary A. Targosz NP 1194845925 Pediatric & Adolescent Care Associates 43184 Dequindre Rd, Suite 208 Sterling Heights, MI 48314 Macomb Shobana Sundaram MD 1932138583 Pediatric & Adolescent Care Associates 43184 Dequindre Rd, Suite 208 Sterling Heights, MI 48314 Macomb Syed Mohiuddin MD 1508937350 Pediatric Health Care 42141 Mound Rd. Sterling Heights, MI 48314 Macomb Abdur Rasheed MD 1487603403 Pediatrics Plus, PLC 27300 Dequindre Road Ste. 222 Sterling Heights, MI 48310 Macomb Zehra Rasheed MD 1598859423 Pediatrics Plus, PLC 27300 Dequindre Road Ste. 222 Sterling Heights, MI 48310 Macomb Carolynn Huyghe NP 1720419195 Shelby Pediatrics 47389 Van Dyke Avenue Shelby Township, MI 48317 Macomb Mohammad Bitar MD 1487877973 Shelby Pediatrics 47389 Van Dyke Avenue Shelby Township, MI 48317 Macomb David Brege MD 1770550709 St. John Pediatric Associates-Macomb 46591 Romeo Plank Suite 205 Macomb Twp, MI 48044 Macomb Eva S. Cristescu MD 1811985583 St. John Pediatric Associates-Macomb 46591 Romeo Plank Suite 205 Macomb Twp, MI 48044 Macomb, Ami Hatta MD 1144478470 Kids First Pediatrics 624 E. 9 Mile Rd. Hazel Park, MI 48030 Oakland, Wayne Manistee Michael Carroll MD 1346338324 Crystal Lake Health Clinic Manistee 2198 US 31 S Manistee, MI 49690 Marquette Christopher Dehlin MD 1588856223 SingleTrack Health PC 107 W. Main Street, Suite 2 Marquette, MI 49855 Marquette Jennifer Dehlin MD 1669699245 SingleTrack Health PC 107 W. Main Street, Suite 2 Marquette, MI 49855 Marquette Ashley Croasdell FNP-BC 1477984607 Upper Great Lakes Family Health Center 135 M553 Gwinn, MI 49841 December 8, 2017 Michigan Department of Health and Human Services Page 15 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Marquette Barbara Wasie FNP 1184827925 Upper Great Lakes Family Health Center 301 Explorer Gwinn Mi 49841 Marquette Emily Starr NP-C 1861893620 Upper Great Lakes Family Health Center 135 E M-35 Gwinn, MI 49841 Mason Craig Matheson DO 1699763953 Craig K Matheson, DO, PLLC DBA Third Coast Family 821 W US Highway 10 Scottville, MI 49454 Practice Mecosta Dr. Carl Schmidt MD 1952485310 Monroe County Health Dept WIC 2353 S. Custer Rd. Monroe, 48161 Mecosta, Joseph Blodgett MD 1699736280 Spectrum Health Med Group- Big Rapids Family Med 650 Linden St. Suite 1 Big Rapids, MI 49307 Allegan, Ottawa Midland Tammy Movsas MD 1285794685 Midland Co Health Dept 220 W. Ellsworth Midland, MI 48640 Midland Denise Schaffert MD 1063810653 Midland Family Physicians 920 W. Wackerly Street Midland, MI 48640 Midland Jeffery T. Archbold DO 1184656159 Midland Family Physicians 920 W. Wackerly Street Midland, MI 48640 Midland Jennifer R. Aloff MD 1013001437 Midland Family Physicians 920 W. Wackerly Street Midland, MI 48640 Midland Lorenzo D. Berlanga MD 1063487411 Midland Family Physicians 920 W. Wackerly Street Midland, MI 48640 Midland Mark S. Ostahowski MD 1184719601 Midland Family Physicians 920 W. Wackerly Street Midland, MI 48640 Midland Adam Hamilton MD 1043484934 MidMichigan Physician Group - Pediatrics 4401 N. Campus Ridge Ste D2400 Midland, MI 48640 Midland Frederick Ogwara MD 1023396579 MidMichigan Physician Group - Pediatrics 4401 N. Campus Ridge Ste D2400 Midland, MI 48640 Midland Mamoon Mohiddin MD 1932209400 MidMichigan Physician Group - Pediatrics 4401 N. Campus Ridge Ste D2400 Midland, MI 48640 Midland Odoma Achor MD 1346552684 MidMichigan Physician Group - Pediatrics 4401 N. Campus Ridge Ste D2400 Midland, MI 48640 Midland Rachel Sawaya MD 1053571786 MidMichigan Physician Group - Pediatrics 4401 N. Campus Ridge Ste D2400 Midland, MI 48640 Monroe Amimul Choudhury MD 1548201080 Amimul A. Choudhury, MD Pediatrics 1052 N Monroe St. Monroe, MI 48162 Monroe Elizabeth Cato NP 1871966911 Amimul A. Choudhury, MD Pediatrics 1052 N Monroe St. Monroe, MI 48162 Monroe Fatima Hassan MD 1750571675 Amimul A. Choudhury, MD Pediatrics 1052 N Monroe St. Monroe, MI 48162 Monroe Jessica Sharon DO 1114127594 Family Medical Center-Carleton 130 Medical Center Drive, Carleton, MI 48117 Monroe Jane Imo NP 1902957129 Family Medical Center-Monroe 905 N. McComb, Suite 3, Monroe, MI 48162 Monroe Kristy Keaton-Baird NP 1730161290 Family Medical Center-Temperance 8765 Lewis Avenue Temperance, MI 48180 Monroe Lekeysha Royster MD 1497934590 Family Medical Center-Temperance 8765 Lewis Avenue Temperance, MI 48180 Monroe Mark Koehl MD 1053399220 Family Medical Center-Temperance 8765 Lewis Avenue Temperance, MI 48180 Monroe Jonathan E. Pasko MD 1962452904 Jonathan E Pasko MD PC 730 N. Macomb Ste 324 Monroe, MI 48162 Monroe Andrea Sue Miller FNP 1629418041 Pediatric and Adolescent Specialists 245 S. Second St. Carson City, MI 48811 Monroe Alicia Gardiner NP 1932407921-OH Pediatric Center Inc-Lambertville 3309 Quail Hollow #C Lamberville, MI 48144 Monroe Edna Vianzon MD 1790761989-OH Pediatric Center Inc-Lambertville 3309 Quail Hollow #C Lamberville, MI 48144 Monroe Jessica Bostater NP 1023412079-OH Pediatric Center Inc-Lambertville 3309 Quail Hollow #C Lamberville, MI 48144 Monroe Kerry Swanton NP 1780784850-OH Pediatric Center Inc-Lambertville 3309 Quail Hollow #C Lamberville, MI 48144 Monroe Sharen Joseph MD 1679851802-OH Pediatric Center Inc-Lambertville 3309 Quail Hollow #C Lamberville, MI 48144 Monroe Jessica Hoffmann NP 1790232650-OH The Pediatric Center, Inc - Franklin Park OHIO 3740 Sylvania Ave Suite 250 Toledo, OH 43623 Monroe Alicia Gardiner NP 1932407921-OH The Pediatric Center, Inc - Oregon OHIO 3156 Dustin Rd Oregon, OH 43616 Montcalm Christina Wilson NP 1295130847 Great Lakes Medical Association 1021 E. Main St. Edmore, MI 48829 Montcalm Sailaja Sarvepalli MD 1194764878 Great Lakes Medical Association 1021 E. Main St. Edmore, MI 48829 Montcalm Stephanie Boring PA 1942398987 Great Lakes Medical Association 1021 E. Main St. Edmore, MI 48829 Montcalm Amber Goetz NP 1295186971 Greenville Family Medicine 1202 W. Oak Greenville, MI 48838 Montcalm Kaushal Kalra MD 1467895606 Greenville Family Medicine 1202 W. Oak Greenville, MI 48838 Montcalm Randi VanOcker DO 1396180337 Greenville Family Medicine 1202 W. Oak Greenville, MI 48838 Montcalm Kira Sieplinga MD 1235346198 Hackley Comm Care Center 2700 Baker Muskegon 49444 Montcalm Debra Ruth House NP 1588943864 Lakeview Family Medicine 418 Washington St. Lakeview, MI 48850 Montcalm Robert Graham DO 1598754731 Mid-Michigan District HD 615 N. State St. Stanton, MI 48888 Montcalm Debra R. House NP 1588943864 Spectrum Health-Lakeview Family Medicine 418 Washington St. Lakeview, MI 48850 Montcalm Lory M. Read DO 1770523524 Spectrum Health-Lakeview Family Medicine 418 Washington St. Lakeview, MI 48850 Montcalm Mark A. del Castillo MD 1215169511 Spectrum Health-Lakeview Family Medicine 418 Washington St. Lakeview, MI 48850 Montmorency Mariana Perinot MD 1740591908 Thunder Bay Community Health Services - Atlanta 11899 M-32 Atlanta, MI 49709 Montmorency Timothy Hayes DO 1497967202 Thunder Bay Community Health Services - Atlanta 11899 M-32 Atlanta, MI 49709 Montmorency Amanda Allen NP 1821453218 Thunder Bay Community Health Services - Hillman 15774 State St. Hillman, MI 49746 Montmorency Cecilia Peasley NP 1164445524 Thunder Bay Community Health Services - Hillman 15774 State St. Hillman, MI 49746 Montmorency Coreen Williams NP 1740236561 Thunder Bay Community Health Services - Hillman 15774 State St. Hillman, MI 49746 Montmorency Jemellee Jacala-Tadian MD 1669681748 Thunder Bay Community Health Services - Hillman 15774 State St. Hillman, MI 49746 December 8, 2017 Michigan Department of Health and Human Services Page 16 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Muskegon Clay Reeves NP 1992015895 Muskegon Famliy Care 2201 S. Getty Muskegon Heights, MI 49444 Muskegon Marco Tatangelo MD 1477992147 Muskegon Famliy Care 2201 S. Getty Muskegon Heights, MI 49444 Muskegon Margaret Wolter NP 1447251442 Muskegon Famliy Care 2201 S. Getty Muskegon Heights, MI 49444 Muskegon Michael Oneka DO 1366457129 Muskegon Famliy Care 2201 S. Getty Muskegon Heights, MI 49444 Muskegon Ramona Wallace DO 1851338891 Muskegon Famliy Care 2201 S. Getty Muskegon Heights, MI 49444 Muskegon Tamra Maben MD 1235240169 Muskegon Famliy Care 2201 S. Getty Muskegon Heights, MI 49444 Muskegon Traci Jones NP 1467493056 Muskegon Famliy Care 2201 S. Getty Muskegon Heights, MI 49444 Muskegon Dr. Derek Lanier MD 4301057270 Oakland Primary Health Services 46 N. Saginaw Pontiac 48342 Oakland Adeela Beg MD 1740336221 Adeela Beg MD PC 24001 Orchard Lake Rd Ste 150 Farmington Hills, MI 48336 Oakland Annamma Pullukat MD 1952419400 Annamma & Roy Pullukat 44200 Woodward Ave, Suite 103 Pontiac, MI 48341 Oakland Roy Pullukat MD 1346537289 Annamma & Roy Pullukat 44200 Woodward Ave, Suite 103 Pontiac, MI 48341 Oakland Joy Friedman MD 1649481813 Beaumont Children's Hospital 4616 Robinwood Ave. Royal Oak, MI 48073 Oakland Stacey A. Shubeck MD 1568473981 Beaumont Health-Pediatrics 3907 Reseda Rd. Waterford, MI 48329 Oakland Carla Oska-Gerak DO 1619107133 Botsford Pediatric Associates 23133 Orchard Lake Road Suite 100 Farmington, MI 48336 Oakland Dilli Ramesh MD 1194767194 Botsford Pediatric Associates 23133 Orchard Lake Road Suite 100 Farmington, MI 48336 Oakland Mirta Soler MD 1538101944 Botsford Pediatric Associates 23133 Orchard Lake Road Suite 100 Farmington, MI 48336 Oakland Tarek Garada MD 1962444679 Botsford Pediatric Associates 23133 Orchard Lake Road Suite 100 Farmington, MI 48336 Oakland Carolyn Gabriel NP 1447527585 Childrens Care Medical Center 30701 Woodward Ave Ste #S301 Royal Oak, MI 48073 Oakland Katherine Yulo MD 1073826301 Childrens Care Medical Center 30701 Woodward Ave Ste #S301 Royal Oak, MI 48073 Oakland Marie McDonald MD 1417964263 Childrens Care Medical Center 30701 Woodward Ave Ste #S301 Royal Oak, MI 48073 Oakland Linda Dillon MD 1891919502 Covenant Community Care Inc - Woodward Clinic 27776 Woodward Ave Royal Oak, MI 48067 Oakland Aurielle Fanning MD 1770933574 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Balteshwar Rana MD 1750765723 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Cheryl Smith MD 1053603860 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Christina Doulaverakis MD 1275916231 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Christina Downey-Biechler DO 1568875797 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Elizabeth Mumaw DO 1841605979 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Gary Otsuji MD 1558361972 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Huong Hannah Tong MD Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Jessica Hudson DO 1144671082 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Kamran Zakaria MD 1710988209 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Karen Mitchell MD 1912906447 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Katherine Cybinski DO 1023420585 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Lauren Robinson MD 1023490653 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Maisee Lor DO 1639551229 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Martha Rumschlag MD 1447251368 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Shahbaz Jamal MD 1649623455 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Shanthiya Sanmugathas MD 1447633649 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Thuy Orlando MD 1336599174 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Victoria Cohen-Bradford DO 1922458751 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Zahid Mahmood MD 1215310867 Deighton Family Practice 22250 Providence Dr. Southfield, MI 48075 Oakland Angela Waldman NP 1629459177 Devyani Khambete, MD 2561 Elizabeth Lake Road Waterford, MI 48328 Oakland Devyani Khambete MD 1518916147 Devyani Khambete, MD 2561 Elizabeth Lake Road Waterford, MI 48328 Oakland Jennifer Crosby NP Devyani Khambete, MD 2561 Elizabeth Lake Road Waterford, MI 48328 Oakland Parvathi Sivarama Krishnan MD 1790872711 Devyani Khambete, MD 2561 Elizabeth Lake Road Waterford, MI 48328 Oakland Sarah Cummings NP 1669815155 Devyani Khambete, MD 2561 Elizabeth Lake Road Waterford, MI 48328 Oakland Beth Baver MD 1184731697 Edgewood Center Pediatrics 8896 Commerce Road Suite 5 Commerce, MI 48382 Oakland Brian Gendelman MD 1316055866 Edgewood Center Pediatrics 8896 Commerce Road Suite 5 Commerce, MI 48382 Oakland Cheryl K. Gannon MD 1447368998 Edgewood Center Pediatrics 8896 Commerce Road Suite 5 Commerce, MI 48382 Oakland Nancy Mansour-Habib MD 1952390031 Grace Medical of Troy 3940 John R. Road Troy, MI 48083 Oakland Hasan Hasaba MD 1558332783 Greenfield Pediatrics 22255 Greenfield Road Southfield, MI 48075 Oakland Ardeshir Irani MD 1497741177 Highland Pediatrics 208 W HIghland Rd Ste 100 Highland, MI 48357 Oakland Christina Ritter NP 1154610855 Kidz 1st Pediatrics 2370 Walton Blvd. Rochester Hills, MI 48309 Oakland Heather Binasio MD 1447519681 Kidz 1st Pediatrics 2370 Walton Blvd. Rochester Hills, MI 48309 December 8, 2017 Michigan Department of Health and Human Services Page 17 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Oakland Silvia Operti-Considne MD 1740267384 Kidz 1st Pediatrics 2370 Walton Blvd. Rochester Hills, MI 48309 Oakland Denise M. Lippitt MD 1922111814 Medical Center Pediatrics 31600 Telegraph Road, Suite 100 Bingham Farms, MI 48025 Oakland Denise Lippitt MD 1922111814 Medical Center Pediatrics-Bingham Farms 31600 Telegraph Rd. Suite 300 Bingham Farms, MI 48025 Oakland Janet Snider MD 1407964034 Medical Center Pediatrics-Bingham Farms 31600 Telegraph Rd. Suite 300 Bingham Farms, MI 48025 Oakland Martin Levinson MD 1346358967 Medical Center Pediatrics-Bingham Farms 31600 Telegraph Rd. Suite 300 Bingham Farms, MI 48025 Oakland Phyllis Meer NP 1053581249 Medical Center Pediatrics-Bingham Farms 31600 Telegraph Rd. Suite 300 Bingham Farms, MI 48025 Oakland Roger Silverstein MD 1013026996 Medical Center Pediatrics-Bingham Farms 31600 Telegraph Rd. Suite 300 Bingham Farms, MI 48025 Oakland Susan Sauber MD 1861504334 Medical Center Pediatrics-Bingham Farms 31600 Telegraph Rd. Suite 300 Bingham Farms, MI 48025 Oakland Evandro Silveira MD 1386672525 Medical Center Pediatrics-West Bloomfield 5793 West Maple Rd, Suite 153 West Bloomfield, MI 48322 Oakland Vicki Solway MD 1679585426 Medical Center Pediatrics-West Bloomfield 5793 West Maple Rd, Suite 153 West Bloomfield, MI 48322 Oakland Agnieszka Smylnyscky MD 1346250578 Metro Medical Practice PC 2891 East Maple Rd. Troy, MI 48083 Oakland Oskana Trotska NP 1124426911 Metro Medical Practice PC 2891 East Maple Rd. Troy, MI 48083 Oakland Pamela L. Berry MD 1811995491 My Kids Doc-Southfield 29255 Northwestern Hwy Suite 100 Southfield, MI 48034 Oakland Kalpana Shah MD 1114900487 My Second Home Pediatrics PLLC 31000 Telegraph Rd Ste 100 Bingham Farms, MI 48025 Oakland Lakshmi Kaza MD 1912997461 My Second Home Pediatrics PLLC 31000 Telegraph Rd Ste 100 Bingham Farms, MI 48025 Oakland Kathy Rosema DO 1689628927 NW MI Health Services 119 S. State St. Shelby, MI 49455 Oakland Ashley K. Parks NP 1366779639 Oakland Primary Health Services 46 N. Saginaw Pontiac 48342 Oakland Dr. J. Tandon Sharma MD 1982613915 Oakland Primary Health Services 46 N. Saginaw Pontiac 48342 Oakland Dr. Preston Thomas MD 1427018571 Oakland Primary Health Services 46 N. Saginaw Pontiac 48342 Oakland LaKeisha Blair-Watson MD 1073755195 Oakland Primary Health Services 46 N. Saginaw Pontiac 48342 Oakland Amy Dunn MD 1558321513 Orchard Pediatrics 6900 Orchard Lk Rd #206 West Bloomfield, MI 48322 Oakland Beth Nadis MD 1184686677 Orchard Pediatrics 6900 Orchard Lk Rd #206 West Bloomfield, MI 48322 Oakland Laurie Fisher MD 1629030929 Orchard Pediatrics 6900 Orchard Lk Rd #206 West Bloomfield, MI 48322 Oakland Sarah Clune DO 1477515963 Orchard Pediatrics 6900 Orchard Lk Rd #206 West Bloomfield, MI 48322 Oakland Seth Faber MD 1720047814 Orchard Pediatrics 6900 Orchard Lk Rd #206 West Bloomfield, MI 48322 Oakland Ceres Guzman-Morales MD 1285631184 Pediatric Consultants of Troy 44199 Dequindre Troy, MI 48085 Oakland Elizabeth Dubina MD 1538166434 Pediatric Consultants of Troy 44199 Dequindre Troy, MI 48085 Oakland Ernestina De Los Sontos-Mac MD 1972590677 Pediatric Consultants of Troy 44199 Dequindre Troy, MI 48085 Oakland Jaime Dreyer MD 1467660779 Pediatric Consultants of Troy 44199 Dequindre Troy, MI 48085 Oakland Laura Warner MD 1952389561 Pediatric Consultants of Troy 44199 Dequindre Troy, MI 48085 Oakland Helen S. Economy MD 1760595425 Pedicatric Care Corner 2300 Haggerty Rd. Suite 2110 West Bloomfield, MI 48323 Oakland Allison Davenport MD 1871943969 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Alyssa Lewandowski DO 1053791848 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Amy Shepard DO 1093837718 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Emily Soni DO 1427292945 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Farvah Fatima MD 1346583796 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Jaquelene Childs MD 1174822506 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Jeffery Lau DO 1780036855 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Kristin Renwick MD 1053761759 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Maria Kostritsyna MD 1649683590 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Monica Kandola MD 1124471933 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Nikolaus Fulbright MD 1235426966 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Nikolaus Fulbright MD 1235426966 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Samuel Ross MD Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Stacey Bartell MD 1669476933 Providence Medical Center South Lyon 210 N Lafayette South Lyon, MI 48178 Oakland Jitty E Alexander PNP-C 1891167599 Regal Pediatrics 2502 Rochester Rd S. Rochester Hills, MI 48307 Oakland Mahmoud Elghourory MD 1124048848 Regal Pediatrics 2502 Rochester Rd S. Rochester Hills, MI 48307 Oakland Rekha Kostecke MD 1285676940 Rekha Kostecke, M.D. 1550 N Milford Rd., Suite 307 Milford, MI 48381 Oakland Farhat Osman MD 1407825243 Rochester Hills Pediatrics 2840 Crooks Road, Ste. 100 Rochester Hills, MI 48309 Oakland Harrietta Christodoulos DO 1033111653 SG Pediatrics 26850 Providence Parkway, Ste. 320 Novi, MI 48374 Oakland Srilakshmi Pinnamaraju MD 1639132541 SG Pediatrics 26850 Providence Parkway, Ste. 320 Novi, MI 48374 Oakland Praveena Sampath MD 1992921621 SG Pediatrics of Lake Orion 1455 South Lapeer Rd. Ste 134 Lake Orion, MI 48360 Oakland Shashi Sahai MD 1932147030 SG Pediatrics of Lake Orion 1455 South Lapeer Rd. Ste 134 Lake Orion, MI 48360 Oakland Kimberly Hoder NP 1518210707 Summit Total Care 1936 N. Pontiac Tr. #A Walled Lake, MI 48095 December 8, 2017 Michigan Department of Health and Human Services Page 18 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Oakland Yasser Hassane MD 1063563476 Summit Total Care 1936 N. Pontiac Tr. #A Walled Lake, MI 48095 Oakland Mohammad Navai MD 1578524245 Summit Total Care-Walled Lake 1936 N. Pontiac Tr. #A Walled Lake, MI 48095 Oakland Mirsida Zholi NP 1467904367 Troy Family Care 41069 Dequindre Rd. #103 Troy, MI 48085 Oakland Nada Hana Bachuri MD 1164502555 Troy Family Care 41069 Dequindre Rd. #103 Troy, MI 48085 Oakland Neda Saker MD 1841278785 Troy Pediatrics 1380 Coolidge Suite 240 Troy, MI 48084 Oakland Sarah P. Degnan NP 1639588007 Troy Pediatrics 1380 Coolidge Suite 240 Troy, MI 48084 Oakland Sharon L. Tice MD 1831177526 Twelve Oaks Pediatrics 44070 Twelve Mile Rd #100 Novi, MI 48377 Oakland Sheryl L Hirsch MD 1366552309 Twelve Oaks Pediatrics 44070 Twelve Mile Rd #100 Novi, MI 48377 Oakland Amy Kowalski MD 1386655702 Union Lake Pediatrics 2630 Union Lake Rd, Suite #100 Commerce Township, MI 48382 Oakland Geetha Nair MD 1235149972 Union Lake Pediatrics 2630 Union Lake Rd, Suite #100 Commerce Township, MI 48382 Oakland Stacey Gorman MD 1457361156 Union Lake Pediatrics 2630 Union Lake Rd, Suite #100 Commerce Township, MI Oakland Dr. Moniruzzaman Khan MD 1477592905 Waterford Pediatrics 4185 Highland Rd Waterford 48328 Oakland Alanna Nzoma MD 1730346495 West Bloomfield Pediatrics -Novi 46325 W 12 Mile Rd Ste 240 Novi, MI 48377 Oakland Anna Strumba MD 1982617627 West Bloomfield Pediatrics -Novi 46325 W 12 Mile Rd Ste 240 Novi, MI 48377 Oakland Seth Forman MD 1568439669 West Bloomfield Pediatrics -Novi 46325 W 12 Mile Rd Ste 240 Novi, MI 48377 Oakland Jennifer Cohen MD 1184647364 West Bloomfield Pediatrics -West Bloomfield 6400 Farmington Rd Ste 10 West Bloomfield, MI 48322 Oakland Misha Yajnik MD 1851612709 West Bloomfield Pediatrics -West Bloomfield 6400 Farmington Rd Ste 10 West Bloomfield, MI 48322 Oakland Steven Glickfield DO 1346356276 West Bloomfield Pediatrics -West Bloomfield 6400 Farmington Rd Ste 10 West Bloomfield, MI 48322 Oakland, Aaron Green MD 1972952000 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Ada L. Kendall MD 1649219502 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Ada L. Kendall MD 1649219502 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Alexander Glaros MD 1114330339 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Alyssa Vermeulen DO 1700291515 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Oakland, Andrea C Hernandez-Troya MD 1639326028 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Oakland, Ashka Atodaria DO 1437566957 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Oakland, Brian Gendelman MD 1316055866 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Oakland, Caroline Meldrum MD 1245679919 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Faeq Al-Mudares MD 1134570534 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Fatima Noorulla MD 1407207889 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Geetika Kennady MD 1922555952 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Hannan J. Alsahlani DO 1689876583 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Idil Daloglu MD 1891101432 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb December 8, 2017 Michigan Department of Health and Human Services Page 19 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Oakland, James Lim MD 1619329406 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Joan Cheng MD 1396872503 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Kalli Jo Doyle MD 1417916818 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Kim Ottoni MD 1053769869 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Kristin Brown DO 1245613710 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Linda Dillon MD 1891919502 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Lolia Abibo MD 1912359795 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Mara Rubenstein MD 1962412874 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Maria Romero Lopez MD 1841641198 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Marisa Elias MD 1326422908 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Mary E. Smyth MD 1497716229 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Olufunke Adeyemo MD 1164813739 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Radhika Vachhani MD 1265815500 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Rita Patel MD 1619194826 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Samuel J. Flanders MD 1003857939 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Sarah Little MD 1629456801 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Terrie Ahn MD 1093166795 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Xinran Xiang MD 1720469133 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb December 8, 2017 Michigan Department of Health and Human Services Page 20 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Oakland, Yahel Weinstein MD 1629393699 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Yusra Abidi MD 1740695048 Beaumont Health-Pediatrics 3535 W. 13 Mile Rd Royal Oak, MI 48073 Wayne, Macomb Oakland, Neda Saker MD 1841278785 Troy Pediatrics 1380 Coolidge Hwy Suite 240 Troy, MI 48084 Macomb Oakland, Sarah Degnan NP 1639588007 Troy Pediatrics 1380 Coolidge Hwy Suite 240 Troy, MI 48084 Macomb Oceana Patricia Jurcich NP MHP Lakeshore Medical Shelby 71 Bevier Street Shelby, MI 49455 Oceana Lisa Helm NP 1538385794 Northwest Michigan Health Services Shelby 119 S. State St. Shelby, MI 49455 Ogemaw Marilyn Louis NP 1871676049 Main Street Family Practice 117 S. Burgess St. West Branch, MI 48661 Osceola Patricia Hoepner MD 1063545226 Spectrum Health-Reed City Family Practice 300 N. Patterson Rd. Reed City, MI 49688 Ottawa Amanda Barton NP 1962595405 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Anna Wassink NP 1417359290 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Beth Peter MD 1306051453 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Cecilia DeCook MD 1407949910 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Charlotte Johnson MD 1235209651 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Eric Gustafson MD 1093809543 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Jeenie Woehl NP 1912090507 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Jill Miedema MD 1083737969 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Jon Kroeze MD 1053405548 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Karla Baker NP 1467545947 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Kurt Lindberg MD 1447344973 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Lisa A. Ondersma-Lowetz NP 1457801250 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Martin Berent MD 1861587362 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Patrick Hulst MD 1831284785 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Robert Bruxvoort MD 1316927775 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Timothy Smith MD 1295828820 Lakewood Family Medicine 382 N 120th Avenue Holland, MI 49424 Ottawa Dr Julia Davey MD 1740282995 Spectrum Health-Grand Haven SHMG Grand Haven Pediatrics 1445 Sheldon Rd. Suite 302 Grand Haven, MI 49417 Ottawa Dr. Karen Wiseman MD 1831222967 Spectrum Health-Grand Haven SHMG Grand Haven Pediatrics 1445 Sheldon Rd. Suite 302 Grand Haven, MI 49417 Ottawa Dr. Lindsay Fox MD 1023200789 Spectrum Health-Grand Haven SHMG Grand Haven Pediatrics 1445 Sheldon Rd. Suite 302 Grand Haven, MI 49417 Ottawa Dr. Michael Warmoth MD 1215932207 Spectrum Health-Grand Haven SHMG Grand Haven Pediatrics 1445 Sheldon Rd. Suite 302 Grand Haven, MI 49417 Ottawa Karen Kerridge NP 1609144724 Spectrum Health-Grand Haven SHMG Grand Haven Pediatrics 1445 Sheldon Rd. Suite 302 Grand Haven, MI 49417 Ottawa, Allegan, Karen Locke MD 1417998709 Lakeshore Health Partners and Internal Medicine/Pediatrics 3235 N. Wellness Dr. Bldg A Suite 120A Holland, MI 49424 Kent Presque Isle Caitlin Ristau NP 1518323450 Thunder Bay Community Health Services - Onaway 21258 West M-68 Hwy Onaway, MI 49765 Presque Isle Elaine Smith DO 1669571444 Thunder Bay Community Health Services - Onaway 21258 West M-68 Hwy Onaway, MI 49765 Presque Isle Julie LaFave NP 1083845937 Thunder Bay Community Health Services - Onaway 21258 West M-68 Hwy Onaway, MI 49765 Presque Isle Cori Williams NP 1710371877 Thunder Bay Community Health Services - Rogers City 205 S. Bradley Hwy. Rogers City, MI 49779 Presque Isle Marion Hautea MD 1962455972 Thunder Bay Community Health Services - Rogers City 205 S. Bradley Hwy. Rogers City, MI 49779 Roscommon Lyndsy McMorrow DO 1023338316 MidMichigan Health Park Houghton Lake 9249 W. Lake City Road Houghton Lake, MI 48629 Saginaw Carolyn Ebert MD 1588878201 Chesaning Family Medicine 300 S. Chapman Chesaning, MI 48616 Saginaw Thomas Teal MD 1811941446 Chesaning Family Medicine 300 S. Chapman Chesaning, MI 48616 Saginaw Robert D. Thill MD 1073513420 Children's Medical Group of Saginaw Bay-Saginaw 3875 Bay Road Suite 1S Saginaw, MI 48603 Saginaw Suart Rupke MD 1083639199 CMU- Family Medicine & Pediatrics 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Amanda Waterman MD 1013397140 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw AMANDEEP DHALIWAL MD 1477873511 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 December 8, 2017 Michigan Department of Health and Human Services Page 21 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Saginaw Amjed Aljanabi MD 1952740680 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Bernard Noveloso MD 1740392190 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Berny Bastiampillai MD 1588048920 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Bilal Shah MD 1104236637 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Blake Putman MD 1659784338 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Delicia Pruitt MD 1407844251 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd Suite 1 Saginaw, MI 48604 Saginaw Edward Sorenson MD 1578902201 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Elizabeth Pagler MD 1295185254 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd Suite 1 Saginaw, MI 48604 Saginaw Erin Hanson NP 1689793663 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Eugene Seals MD 1053309880 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd Suite 1 Saginaw, MI 48604 Saginaw George Gugino MD 1528026663 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Hafsa Hashmi MD 1316385289 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw James Putman MD 1053799486 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Jamuna Manoharan MD 1376927228 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Janet Adner NP 1639310279 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd Suite 1 Saginaw, MI 48604 Saginaw Jennifer Romeu MD 1285089425 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd Suite 1 Saginaw, MI 48604 Saginaw Karensa Franklin MD 1528418340 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd Suite 1 Saginaw, MI 48604 Saginaw Lawrence Whiting MD 1700147519 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Madhumitha Krishnamoorthy MD 1124438445 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Mary Moore MD 1275502445 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd Suite 1 Saginaw, MI 48604 Saginaw Matthew Holden MD 1578913265 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd Suite 1 Saginaw, MI 48604 Saginaw Michelle Storms MD 1811988959 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Nadezda Stelmaschuk MD 1467867564 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Niharika Perni MD 1063894905 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Palak Shroff MD 1487094090 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Puneet Bhalrhu MD 1174962898 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Rita Agayby MD 1952855298 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd Suite 1 Saginaw, MI 48604 Saginaw Robert VanHowe MD 1780686246 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Sagar Patel MD 1720498843 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Samhar M. Alali MD 1053675462 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Snehal Reddy MD 1053731497 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Stephen Smith MD 1467716191 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Trina Hara MD 1710369186 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Triptpal Sanghera MD 1598211823 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd Suite 1 Saginaw, MI 48604 Saginaw Triptpal Sanghera MD CMU Medical Education Partners-Family Residency 1575 Concentric Blvd Suite 1 Saginaw, MI 48604 Saginaw Vikas Reddy MD 1295099596 CMU Medical Education Partners-Family Residency 1575 Concentric Blvd, Suite 1 Saginaw, MI 48604 Saginaw Roy Small DO 1841245370 Dr. Small - Memorial Healthcare 9000 Peet Rd. Chesaning, MI 48616 Saginaw Elvira M. Dawis MD 1952350571 Elvira M. Dawis MD FAAP PC 144 N. Frost Drive, Suite 2 Saginaw, MI 48638 Saginaw Carmen C. Szilagyi MD 1043208580 Frankenmuth Family Physicians-St. Mary's 1027 W. Genesee Frankenmuth, MI 48734 Saginaw Janet M. Bach DO 1083602510 Frankenmuth Family Physicians-St. Mary's 1027 W. Genesee Frankenmuth, MI 48734 Saginaw Patrick J. Botz DO 1447248968 Frankenmuth Family Physicians-St. Mary's 1027 W. Genesee Frankenmuth, MI 48734 Saginaw Rebecca Boensch NP 1063412690 Frankenmuth Family Physicians-St. Mary's 1027 W. Genesee Frankenmuth, MI 48734 Saginaw Amanda Graham NP 1447500137 GLBHC-Bridgeport 6297 Dixie Highway Bridgeport, MI 48722 Saginaw Dakima Bridges NP 1659645125 GLBHC-Bridgeport 6297 Dixie Highway Bridgeport, MI 48722 Saginaw Ancy Abraham NP 1942686464 GLBHC-David R Gamez 501 Lapeer Avenue Saginaw, MI 48607 Saginaw Ashley Gardner NP 1467902825 GLBHC-David R Gamez 501 Lapeer Avenue Saginaw, MI 48607 Saginaw Smriti Pant NP 1538518071 GLBHC-David R Gamez 501 Lapeer Avenue Saginaw, MI 48607 Saginaw Brenda Coughlin MD 1609864495 GLBHC-Janes St. 1522 Janes Street Saginaw, MI 48601 Saginaw Donald Passal MD 1033107867 GLBHC-Janes St. 1522 Janes Street Saginaw, MI 48601 Saginaw Janell Jordan-Turner NP 1447611900 GLBHC-Janes St. 1522 Janes Street Saginaw, MI 48601 Saginaw Jennifer Dietzel NP 1376973073 GLBHC-Janes St. 1522 Janes Street Saginaw, MI 48601 Saginaw Shauna Barbeau NP 1053470963 GLBHC-Janes St. 1522 Janes Street Saginaw, MI 48601 Saginaw Shirley Raveendran MD 1245523349 GLBHC-Janes St. 1522 Janes Street Saginaw, MI 48601 December 8, 2017 Michigan Department of Health and Human Services Page 22 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Saginaw Shannon Murphy NP 1285050278 GLBHC-Old Town 804 S Hamilton Saginaw, MI 48602 Saginaw Michael Busch NP 1235680331 GLBHC-Ruffin 229 Gallagher Saginaw, MI 48601 Saginaw Terilynn Harrison NP 1124414966 GLBHC-Ruffin 229 Gallagher Saginaw, MI 48601 Saginaw Amanda Byler NP 1720325947 GLBHC-Saginaw High School Based Saginaw Takesha Essex NP 1972984870 GLBHC-Saginaw High School Based Saginaw Lawrence L. La Londe MD 1205811551 Lawrence L. Lalonde MD PC 5421 N. Colony Drive Saginaw, MI 48638 Saginaw Gayatri Shanker MD 1558466920 Partners in Pediatrics 4684 Wenmar Dr. Saginaw, MI 48604 Saginaw Lisa Jean NP 1700189859 Partners in Pediatrics 4684 Wenmar Dr. Saginaw, MI 48604 Saginaw Shelley Ridgway NP 1184947210 Partners in Pediatrics 4684 Wenmar Dr. Saginaw, MI 48604 Saginaw Shelley Sibbold NP 1336519198 Partners in Pediatrics 4684 Wenmar Dr. Saginaw, MI 48604 Saginaw Yvonne V. Pacquing MD 1215032644 Partners in Pediatrics 4684 Wenmar Dr. Saginaw, MI 48604 Saginaw Jorge Plasencia MD 1760466346 Plasencia Family Medicine 4705 Town Center Rd. Ste 202 Saginaw, MI 48604 Saginaw Beth Fettinger NP 1073611851 Saginaw Valley Pediatrics 5821 Colony Dr. N Saginaw, MI 48638 Saginaw Mohammad Y. Khan MD 1033116512 Saginaw Valley Pediatrics 5821 Colony Dr. N Saginaw, MI 48638 Saginaw Thomas M. Burkey MD 1134125701 Saginaw Valley Pediatrics 5821 Colony Dr. N Saginaw, MI 48638 Saginaw Douglas B. Forsyth MD 1467440172 St. Mary's Chesaning Health Center 1600 W. Brady Chesaning, MI 48616 Saginaw Susan M. Jaskiewicz NP 1649270349 St. Mary's Chesaning Health Center 1600 W. Brady Chesaning, MI 48616 Sanilac Matthew Gormley MD 1235324385 McKenzie Croswell Clinic 8 N. Howard Avenue Croswell, MI 48422 Sanilac Nicole Liccardello NP 1134539265 McKenzie Croswell Clinic 8 N. Howard Avenue Croswell, MI 48422 Sanilac Michael Merkler MD 1962493213 McKenzie Family Healthcare 109 N. Delaware Street Sandusky, MI 48471 Sanilac Suzette Walker NP 1558492850 McKenzie Health and Wellness Center 170 W. Argyle Street Sandusky, MI 48471 Sanilac James L. Sams MD 1568463800 McKenzie Peck Medical Center 251 E. Peck Road Peck, MI 48466 Sanilac Stephanie Peruski NP 1003285024 McKenzie Peck Medical Center 251 E. Peck Road Peck, MI 48466 Sanilac Brandy Trepkowski NP 1841432176 McKenzie Rural Health Clinic 75 Dawson Street Sandusky, MI 48471 Sanilac Maria Budai MD 1356390900 Pediatric and Adolescent Services 2055 W.Garrison Rd Owosso, Mi 48867 Sanilac Dr. Russell Bush MD 1144287798 Sanilac Co HD 171 Dawson Sandusky, MI 48471 Sanilac Angela Weber NP 1427082510 Sanilac Co Health Department 171 Dawson Sandusky, MI 48471 Sanilac Shannon Nowiski NP 1518337799 State Street Medical Clinic 233 State Street Harbor Beach, MI 48441 Shiawassee Andrea Miller FNP-BC 1629418041 Arnold Medical Clinic 1975 W. M-21 Suite 104 Owosso, MI 48867 Shiawassee Anthony Patsy DO 1760652655 Arnold Medical Clinic 1975 W. M-21 Suite 104 Owosso, MI 48867 Shiawassee Krisha Horger NP 1780639302 Arnold Medical Clinic 1975 W. M-21 Suite 104 Owosso, MI 48867 Shiawassee Manjali Shastry MD 1801990254 Dr. Shastry's Office 1787 S. M-52 Owosso, MI 48867 Shiawassee Angie Kujacznski NP 1578502522 Durand Family Health Center 9099 East Lansing Road Durand, MI 48429 Shiawassee Diane Gutchak NP 1780723015 Durand Family Health Center 9099 East Lansing Road Durand, MI 48429 Shiawassee Gerri Hagadon NP 1831193358 Durand Family Health Center 9099 East Lansing Road Durand, MI 48429 Shiawassee Dr. Todd Welton DO 1063601250 Intercare Community Health Network 308 Charles Bangor 49013 Shiawassee Arlanda Smith WHNP 1679917322 Laingsburg Primary Care 317 E. Grand River Laingsburg, MI 48848 Shiawassee Barbara Gurden DO 1063465631 Laingsburg Primary Care 317 E. Grand River Laingsburg, MI 48848 Shiawassee Cindy Reichert-Brooks FNP 1154571875 Laingsburg Primary Care 317 E. Grand River Laingsburg, MI 48848 Shiawassee Jonathan King MD 1437447414 Laingsburg Primary Care 317 E. Grand River Laingsburg, MI 48848 Shiawassee Carol Vorenkamp DO 1669461992 Memorial Family Medicine 826 WEST KING STREET Owosso, MI 48867 Shiawassee Kristina Yaklin NP 1285075085 Memorial Northside Family Medicine 1457 N M-52 Unit #2 Owosso, MI 48867 Shiawassee Bethany Pavon NP 1619374808 Memorial Pediatric Clinic 802 W. King St. Suite C Owosso, MI 48867 Shiawassee Bethany Pavon NP 1619374808 Memorial Pediatric Clinic 802 W. King St. Owosso, MI 48867 Shiawassee Michael Kramer DO 1831497338 Memorial Pediatric Clinic 802 W. King St. Suite C Owosso, MI 48867 Shiawassee Michael Kramer DO 1831497338 Memorial Pediatric Clinic 802 W. King St. Owosso, MI 48867 Shiawassee Maria Budai MD 1356390900 Pediatric and Adolescent Services 802 W. King St., Suite J Owosso, MI 48867 Shiawassee Amy Blaising-Wallace DO 1356380950 Perry Family Practice 3337 Britton Road Perry, MI 48872 Shiawassee Usman Ahmed DO 1043507049 Perry Family Practice 3337 Britton Road Perry, MI 48872 Shiawassee Kristi Kusnier MD 1528285095 Schoolcraft Memorial Rural Health Clinic 7870 W. US2 Manistique, MI 49854 Shiawassee Adriana Raus MD 1306080536 Shiawassee Family Medicine 239 N. State Road Owosso, MI 48867 St. Clair Elizabeth A. Hall DO 1336459221 St. John Pediatric Associates-St. Clair Shores 21931 E. 9 Mile Rd St. Clair Shores, MI 48080 St. Clair Lyric Green MD 1205825957 St. John Pediatric Associates-St. Clair Shores 21931 E. 9 Mile Rd St. Clair Shores, MI 48080 December 8, 2017 Michigan Department of Health and Human Services Page 23 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: St. Clair Mohamad S. Saberi MD 1124013750 St. John Pediatric Associates-St. Clair Shores 21931 E. 9 Mile Rd St. Clair Shores, MI 48080 St. Clair Patricia L. Tieman NP 1639535362 St. John Pediatric Associates-St. Clair Shores 21931 E. 9 Mile Rd St. Clair Shores, MI 48080 St. Clair Paula K. Schreck MD 1437135431 St. John Pediatric Associates-St. Clair Shores 21931 E. 9 Mile Rd St. Clair Shores, MI 48080 St. Clair Shakeela F. Mirza MD 1902856578 St. John Pediatric Associates-St. Clair Shores 21931 E. 9 Mile Rd St. Clair Shores, MI 48080 St. Clair Sharon Fowler MD 1881682334 St. John Pediatric Associates-St. Clair Shores 21931 E. 9 Mile Rd St. Clair Shores, MI 48080 St. Joseph Ami Shah MD 1336272459 St. Joseph Pediatrics 3800 Hollywood Suite 102 St. Joseph, MI 49085 St. Joseph Debasree Ghosh MD 1740509579 St. Joseph Pediatrics 3800 Hollywood Suite 102 St. Joseph, MI 49085 St. Joseph Mukund Shah MD 1013086446 St. Joseph Pediatrics 3800 Hollywood Suite 102 St. Joseph, MI 49085 Tuscola Marlene Schank NP 1235467887 Hills & Dales: Cass City Medical Practice 4674 Hill St Cass City, MI 48726 Tuscola Marie Havercamp NP 1609240316 Hills & Dales-Cass City Family Practice 6190 Hospital Drive Cass City, MI 48726 Tuscola Elizabeth Paling NP 1265511653 Hills & Dales-Family Healthcare of Cass City 6230 Hospital Drive Cass City, MI 48762 Tuscola Erica Knoerr NP 1356734172 Hills & Dales-Kingston Family Practice 5854 State Street Kingston, MI 48741 Tuscola Melanie Kramer MD 1548291982 Hills & Dales-Kingston Family Practice 5854 State Street Kingston, MI 48741 Tuscola Andrea Mosher NP 1093197998 Hills & Dales-Thumb Pediatrics 6190 Hospital Drive Suite 105 Cass City, MI 48726 Tuscola Darcy Schlund-Tenbusch NP 1346256401 Hills & Dales-Thumb Pediatrics 6190 Hospital Drive Suite 105 Cass City, MI 48726 Tuscola Angie Weber NP 1043424468 Hills & Dales-Ubly Medical Practice 2254 Main Street Ubly, MI 48475 Tuscola Arup Sarkar MD 1477548899 St. Mary's of Michigan-Vassar 1212 W. Saginaw Road Vassar, MI 48768 Tuscola Bridget Young NP 1003228040 St. Mary's of Michigan-Vassar 1212 W. Saginaw Road Vassar, MI 48768 Tuscola Jill Moore NP 1104811215 St. Mary's of Michigan-Vassar 1212 W. Saginaw Road Vassar, MI 48768 Tuscola Dr. Russell Bush MD 1144287798 Tuscola Co Health Dept 1309 Cleaver Rd Ste B Caro, MI 48723 Van Buren Jessica Segedy DO 1114213154 ProMed Pediatrics 24466 Red Arrow Highway Mattawan, MI 49071 Van Buren John Spitzer MD 1164530077 ProMed Pediatrics 24466 Red Arrow Highway Mattawan, MI 49071 Washtenaw Allen Dumont MD 1528020492 Allen Dumont PC 911 Brown St Ann Arbor 48104 Washtenaw Amy Mikhall MD 1497716112 Allen Dumont PC 911 Brown St Ann Arbor 48104 Washtenaw Karen Kopicko CPNP 1801857669 Allen Dumont PC 911 Brown St Ann Arbor 48104 Washtenaw Susan Harris MD 1194787424 Allen Dumont PC 911 Brown St Ann Arbor 48104 Washtenaw Dr. Ajey Godbole MD 1407858319 Brentwood Pediatrics 33215 7 Mile Rd Livonia 48152 Washtenaw Dr. Amanda Dempsey MD 1497761654 Briarwood Health Assoc 325 Briarwood Circle Bldg 5 Ann Arbor 48108 Washtenaw Dr. Kristin Cutlan MD 1821112442 Briarwood Health Assoc 325 Briarwood Circle Bldg 5 Ann Arbor 48108 Washtenaw Dr. Lisa Hammer MD 1497761647 Briarwood Health Assoc 325 Briarwood Circle Bldg 5 Ann Arbor 48108 Washtenaw Dr. Sharon Kileny MD 1720002959 Briarwood Health Assoc 325 Briarwood Circle Bldg 5 Ann Arbor 48108 Washtenaw Dr. Yolaine Civil MD 1013025691 Briarwood Health Assoc 325 Briarwood Circle Bldg 5 Ann Arbor 48108 Washtenaw Kathryn Fessler MD, PhD 1902873797 Corner Health Center 47 N. Huron Ypsilanti, MI 48197 Washtenaw Margaret Riley MD 1699894014 Corner Health Center 47 N. Huron Ypsilanti, MI 48197 Washtenaw Tammy Chang MD 1801094966 Corner Health Center 47 N. Huron St. Ypsilanti, MI 48197 Washtenaw Brittany Raburn MD 1831415082 IHA Chelsea Pediatrics 1513 S Main Street Chelsea, MI 48118 Washtenaw Chung-Ming E. Heung MD 1639146434 IHA Chelsea Pediatrics 1513 S Main Street Chelsea, MI 48118 Washtenaw John Gardner MD 1720055213 IHA Chelsea Pediatrics 1513 S Main Street Chelsea, MI 48118 Washtenaw Siobhan Gorman RN, NP 1720131527 IHA Chelsea Pediatrics 1513 S Main Street Chelsea, MI 48118 Washtenaw Susanna Lin MD 1073695060 IHA Chelsea Pediatrics 1513 S Main Street Chelsea, MI 48118 Washtenaw Tara Kelly MD 1336104488 IHA Chelsea Pediatrics 1513 S Main Street Chelsea, MI 48118 Washtenaw Brian Bluhm MD 1134327281 IHA Family & Internal Medicine - WestArbor 4350 Jackson Road, Suite 200 Ann Arbor, MI 48103 Washtenaw Hongyan Yang MD 1780996199 IHA Family & Internal Medicine - WestArbor 4350 Jackson Road, Suite 200 Ann Arbor, MI 48103 Washtenaw Jane Klaes DO 1538276662 IHA Family & Internal Medicine - WestArbor 4350 Jackson Road, Suite 200 Ann Arbor, MI 48103 Washtenaw Michael Bruderly MD 1164480141 IHA Family & Internal Medicine - WestArbor 4350 Jackson Road, Suite 200 Ann Arbor, MI 48103 Washtenaw Nathan Mahany MD 1861735854 IHA Family & Internal Medicine - WestArbor 4350 Jackson Road, Suite 200 Ann Arbor, MI 48103 Washtenaw Nicole Kohnen MD 1992965651 IHA Family & Internal Medicine - WestArbor 4350 Jackson Road, Suite 200 Ann Arbor, MI 48103 Washtenaw Ramachandra Krishnashastry MD 1285998369 IHA Family & Internal Medicine - WestArbor 4350 Jackson Road, Suite 200 Ann Arbor, MI 48103 Washtenaw Steven Thiry MD 1427169267 IHA Family & Internal Medicine - WestArbor 4350 Jackson Road, Suite 200 Ann Arbor, MI 48103 Washtenaw Tanya Rodgers MD 1619945151 IHA Family & Internal Medicine - WestArbor 4350 Jackson Road, Suite 200 Ann Arbor, MI 48103 Washtenaw Melissa Sokol-Keith MD 1972571412 IHA Family Medicine - Arbor Park 4940 W. Clark Rd., Suite 100 Ypsilanti, MI 48197 Washtenaw Robert Breakey MD 1063481281 IHA Family Medicine - Arbor Park 4940 W. Clark Rd., Suite 100 Ypsilanti, MI 48197 Washtenaw Roger Chan MD 1245207836 IHA Family Medicine - Arbor Park 4940 W. Clark Rd., Suite 100 Ypsilanti, MI 48197 Washtenaw Shannon Kusiak MD 1346401601 IHA Family Medicine - Arbor Park 4940 W. Clark Rd., Suite 100 Ypsilanti, MI 48197 December 8, 2017 Michigan Department of Health and Human Services Page 24 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Washtenaw Therese Berevich MD 1285651240 IHA Family Medicine - Arbor Park 4940 W. Clark Rd., Suite 100 Ypsilanti, MI 48197 Washtenaw Vaishali Katial MD 1649373093 IHA Family Medicine - Arbor Park 4940 W. Clark Rd., Suite 100 Ypsilanti, MI 48197 Washtenaw Elizabeth Stone MD 1053416081 IHA- Pediatric Healthcare Assoc 4936 W. Clark #101 Ypsilanti 48197 Washtenaw Karen Brenner MD 1851368591 IHA- Pediatric Healthcare Assoc 4937 W. Clark #101 Ypsilanti 48197 Washtenaw Roy L. Rosen MD 1427140672 IHA- Pediatric Healthcare Assoc 4937 W. Clark #101 Ypsilanti 48197 Washtenaw Amy Cooke MD 1316914906 IHA Primary Pediatrics 4200 Whitehall Dr #230 Ann Arbor, MI 48105 Washtenaw Frances Youssef MD 1669440160 IHA Primary Pediatrics 4200 Whitehall Dr #230 Ann Arbor, MI 48105 Washtenaw Monica Montemayor MD 1588782056 IHA Primary Pediatrics 4200 Whitehall Dr #230 Ann Arbor, MI 48105 Washtenaw Patrick Gordon MD 1972627701 IHA Primary Pediatrics 4200 Whitehall Dr #230 Ann Arbor, MI 48105 Washtenaw Linda Repasky NP 1528102118 IHA_Pediatric Health Care Associates 709 Cambridge Ypsilanti Mi 48197 Washtenaw Adrianna Benedetto NP 1699149880 IHA-Pediatric Healthcare Arbor Park 4936 W. Clark Road, Ste. 101 Ypsilanti, MI 48197 Washtenaw Julie Lazarus MD 1700173325 IHA-Pediatric Healthcare Arbor Park 4936 W. Clark Road, Ste. 101 Ypsilanti, MI 48197 Washtenaw Karen Brenner MD 1851368591 IHA-Pediatric Healthcare Arbor Park 4936 W. Clark Road, Ste. 101 Ypsilanti, MI 48197 Washtenaw Kathleen Davis NP 1093868861 IHA-Pediatric Healthcare Arbor Park 4936 W. Clark Road, Ste. 101 Ypsilanti, MI 48197 Washtenaw Linda Repasky NP 1528102118 IHA-Pediatric Healthcare Arbor Park 4936 W. Clark Road, Ste. 101 Ypsilanti, MI 48197 Washtenaw Melissa Schroeter NP 1457404907 IHA-Pediatric Healthcare Arbor Park 4936 W. Clark Road, Ste. 101 Ypsilanti, MI 48197 Washtenaw Neal Weinberg MD 1699886440 IHA-Pediatric Healthcare Arbor Park 4936 W. Clark Road, Ste. 101 Ypsilanti, MI 48197 Washtenaw Nicole Frei MD 1437260338 IHA-Pediatric Healthcare Arbor Park 4936 W. Clark Road, Ste. 101 Ypsilanti, MI 48197 Washtenaw Roy Rosen MD 1427140672 IHA-Pediatric Healthcare Arbor Park 4936 W. Clark Road, Ste. 101 Ypsilanti, MI 48197 Washtenaw Anastasia Floros MD 1275948432 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Edward Kresyman DO 1053762641 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Gerald Tomasek MD 1073928149 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw John Awad MD 1528419173 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Jon-Davy Palmer MD 1861874000 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Judith Aranas MD 1013399104 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Kevin Sullivan MD 1346656170 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Khac Le MD 1982055521 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Long Nguyen MD 1700237468 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Lynn Ngo MD 1508271750 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Megan Feng MD 1770901779 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Nicholas Noble DO 1316329329 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Nicholas Pryomski MD 1760897912 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Rachel Allen MD 1952752503 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Ray Abarintos MD 1417339516 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Tomoyasu Higashimoto DO 1902219165 Promedica Monroe Regional Hospital Family Medicine 650 Stewart Road Monroe, MI 48162 Residency Washtenaw Bassel Atasi MD 1952507055 St. Joseph Mercy Neighborhood Family Health Center 111 N. Huron St., Suite 200 Ypsilanti, MI 48197 Washtenaw Corey Dean MD 1235166042 St. Joseph Mercy Neighborhood Family Health Center 111 N. Huron St., Suite 200 Ypsilanti, MI 48197 Washtenaw Sara Platte MD 1336359426 St. Joseph Mercy Neighborhood Family Health Center 111 N. Huron St., Suite 200 Ypsilanti, MI 48197 December 8, 2017 Michigan Department of Health and Human Services Page 25 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Washtenaw Suzette La Vigne MD 1891722740 St. Joseph Mercy Neighborhood Family Health Center 111 N. Huron St., Suite 200 Ypsilanti, MI 48197 Washtenaw Dr. David Thorrez MD 1558364562 Thorrez Medical Practice 2900 Packard Suite 1 Ypsilanti 48197 Washtenaw Debra Boyer MD 1760549281 Thorrez Medical Practice, PLC 2900 Packard Ste. 1 Ypsilanti Mi 48197 Washtenaw Kathryn Fenton NP 1760899595 Thorrez Medical Practice, PLC 2900 Packard Ste. 1 Ypsilanti Mi 48197 Washtenaw Lindsey A. Mitzel CPNP 1679990253 Thorrez Medical Practice, PLC 2900 Packard Ste. 1 Ypsilanti Mi 48197 Washtenaw Anthony Wong MD 1528441326 U of M 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Dr. Sara Laule MD 1598099145 U of M 4260 Plymouth Rd Ann Arbor 48109 Washtenaw Priyanka Kalapurayil MD 1033559117 U of M 14700 E Old US Hwy 12, Chelsea, MI 48118 Washtenaw Dr. Joseph Zickafoose MD 1053524421 U of M Briarwood Center for Children and Young Adults 400 E. Eisenhower Prkwy, Suite B Ann Arbor 48108 Washtenaw Anna Laurie MD 1619231842 U of M Briarwood Family Practice 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Dr. Adrienne Musci Pediatrician 1639183809 U of M- East Medical Campus 4260 Plymouth Rd Ann Arbor 48109 Washtenaw Dr. Dolores Mendelow MD 1336153527 U of M- East Medical Campus 4260 Plymouth Rd Ann Arbor 48109 Washtenaw Dr. Heather Burrows MD 1992819320 U of M- East Medical Campus 4260 Plymouth Rd Ann Arbor 48109 Washtenaw Dr. Lisa Saab-Abazeed MD 1750414884 U of M- East Medical Campus 4260 Plymouth Rd Ann Arbor 48109 Washtenaw Dr. Paramjeet Kochhar MD 1588678858 U of M- East Medical Campus 4260 Plymouth Rd Ann Arbor 48109 Washtenaw Jessica Fealy MD 1083874713 U of M Med-Briarwood Center for Women, Children, and 400 E Eisenhower Pkwy, Suite B Ann Arbor, MI 48108 Young Adults Washtenaw Kelly Orringer MD 1790799971 U of M Med-Briarwood Center for Women, Children, and 400 E Eisenhower Pkwy, Suite B Ann Arbor, MI 48108 Young Adults Washtenaw Kristen Auwarter MD 1396066890 U of M Med-Briarwood Center for Women, Children, and 400 E Eisenhower Pkwy, Suite B Ann Arbor, MI 48108 Young Adults Washtenaw Lauren Helms MD 1780896423 U of M Med-Briarwood Center for Women, Children, and 400 E Eisenhower Pkwy, Suite B Ann Arbor, MI 48108 Young Adults Washtenaw Nancy Ferry NP 1679790752 U of M Med-Briarwood Center for Women, Children, and 400 E Eisenhower Pkwy, Suite B Ann Arbor, MI 48108 Young Adults Washtenaw Sharon Kileny MD 1720002959 U of M Med-Briarwood Center for Women, Children, and 400 E Eisenhower Pkwy, Suite B Ann Arbor, MI 48108 Young Adults Washtenaw Dr. Gina Ney MD 1922394360 U of M Mott Childrens 3009 Barclay Way Ann Arbor, MI 48105 Washtenaw Mayya Malakh MD 1326426677 U of M Pediatric Residency 1500 E Medical Center Drive Ann Arbor, MI 48109 Washtenaw Dr. Gwen Zirngibl MD 1578723201 U of M Residency program 325 Briarcrest #177 Ann Arbor 48104 Washtenaw Dr. Laura Peterson MD 1982048617 U of M Ypsilanti Health Center 200 Arnet Suite 200 Ann Arbor, MI 48198 Washtenaw Jaclyn Barrett NP 1861642712 U of M Ypsilanti Health Center 200 Arnet St. Suite 200 Ypsilanti 48198 Washtenaw Mikel Llanes MD 1205034378 U of M Ypsilanti Health Center 200 Arnet St. Suite 200 Ypsilanti 48198 Washtenaw Christina Lindell MD 1295815074 U of M Ypsilanti Pediatrics 200 Arnet St. Suite 200 Ypsilanti 48198 Washtenaw Dr. Sana Ahmed MD 1235263179 U of M Ypsilanti Pediatrics 200 Arnet St. Suite 200 Ypsilanti 48198 Washtenaw Miriam Bornhorst MD 1639339369 U of M Ypsilanti Pediatrics 200 Arnet St. Suite 200 Ypsilanti 48198 Washtenaw Sharon Swindell MD 1639231467 U of M Ypsilanti Pediatrics 200 Arnet St. Suite 200 Ypsilanti 48198 Washtenaw Stephanie Hudson MD 1326159435 U of M Ypsilanti Pediatrics 200 Arnet St. Suite 200 Ypsilanti 48198 Washtenaw Adrienne Musci MD 1639183809 University of Michigan-East Pediatric Clinic 4260 Plymouth Road Ann Arbor, MI 48109 Washtenaw Alison Dickson MD 1740476688 University of Michigan-East Pediatric Clinic 4260 Plymouth Road Ann Arbor, MI 48109 Washtenaw Gwendolyn Zirngibl MD 1578723201 University of Michigan-East Pediatric Clinic 4260 Plymouth Road Ann Arbor, MI 48109 Washtenaw Heather Burrows MD 1992819320 University of Michigan-East Pediatric Clinic 4260 Plymouth Road Ann Arbor, MI 48109 Washtenaw Paramjeet Kochhar MD 1588678858 University of Michigan-East Pediatric Clinic 4260 Plymouth Road Ann Arbor, MI 48109 Washtenaw Sara M. Laule MD 1598099145 University of Michigan-East Pediatric Clinic 4260 Plymouth Road Ann Arbor, MI 48109 Washtenaw Anne Murphy MD 1841671898 Uof M Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Clinton Cochran MD 1194161612 Uof M Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Jennifer Hemberg MD 1114330685 Uof M Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Julie Barrett MD 1235510256 Uof M Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Shannon Taut MD 1265845770 Uof M Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Jill Noble MD 1295745818 Uof M Med-Saline Health Center 700 Woodland Dr. Saline, MI 48176 Washtenaw Maya Holtrop MD 1144596545 Uof M Med-Saline Health Center 700 Woodland Dr. Saline, MI 48176 Washtenaw Steve Park MD 1699781864 Uof M Med-Saline Health Center 700 Woodland Dr. Saline, MI 48176 Washtenaw Aarti Raheja MD 1255446258 UofM Med West Ann Arbor Health Center 4900 Jackson Rd Ste A Ann Arbor, MI 48013 Washtenaw Sara Sandvig MD 1245244482 UofM Med West Ann Arbor Health Center 4900 Jackson Rd Ste A Ann Arbor, MI 48013 December 8, 2017 Michigan Department of Health and Human Services Page 26 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Washtenaw Shaili Rajput MD 1427344829 UofM Med West Ann Arbor Health Center 4900 Jackson Rd Ste A Ann Arbor, MI 48013 Washtenaw Amanda DeLong MD 1255777876 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Ashleigh El Sakr MD 1003254244 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Aviva Alpert MD 1295171759 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Brittany Allen MD 1013352566 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Chinaemerem Agbakwuru MD 1467865915 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Christina Grech MD 1528328515 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Christopher Mathis MD 1184003345 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Colleen Mathis MD 1689052938 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Elizabeth Ames MD 1609256064 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Jason Fischer MD 1235574781 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Jason Metcalf MD 1801246558 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Kayla Bronder MD 1114304433 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Kevin Walker MD 1265846158 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Kimberly Levitt MD 1992183248 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Kristi Huisinga MD 1770960098 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Kyle Pohl MD 1013278092 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Leeann Pavlek MD 1255744181 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Maysa Hamade MD 1003294844 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Michael Triebwasser MD 1073991329 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Niyomi Gandhi MD 1639557481 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Rachel Smith MD 1285085928 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Rebecca Lane MD 1487031704 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Rebekah Diamond MD 1164800264 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Stephanie Booms MD 1912342460 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Stephanie Royer MD 1366703340 UofM Med-Pediatric Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Alisa Young MD 1801059548 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Anita Hernandez MD 1306073986 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Carissa Orizondo MD 1124348321 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Catherine Bettcher MD 1154419646 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw David Serlin MD 1962591826 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Ebony Parker-Featherstone MD 1578682639 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Gary Yen MD 1497844351 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Hetal Choxi MD 1912261132 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Jean Malouin MD 1376632224 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Keri Denay MD 1619175775 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Kristina Gallagher MD 1902994429 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Mack T. Ruffin MD 1245329101 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Phillip Rodgers MD 1063501914 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Ricardo Bartelme MD 1174611669 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Scott Kelley MD 1144348970 UofM-Briarwood Family Medicine 1801 Briarwood Circle, Building 10 Ann Arbor, MI 48108 Washtenaw Aleksandr Belakovskiy MD 1740663525 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Aleksandr Belakovskiy MD 1740663525 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Eric Skye MD 1871682732 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Erica Martin MD 1598148389 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Ghazwan Toma MD 1700047420 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Grant Greenberg MD 1245328772 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Gregory D. Shumer MD 1164862249 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Heather J. McGovern MD 1902246085 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Jacqueline M. Harrison Blunck MD 1295140267 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw James Cooke MD 1942398458 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw James Peggs MD 1548359490 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Jenna Greenberg MD 1568726792 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Jill Fenske MD 1255354007 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 December 8, 2017 Michigan Department of Health and Human Services Page 27 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Washtenaw John O'Brien MD 1639268584 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Justin Oldfield MD 1457766438 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Karen Musolf MD 1285723130 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Katherine A. VanDrunen MD 1154761237 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Ketti Petersen MD 1003128919 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Kristine L. Cece MD 1386084465 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Margaret Dobson MD 1164620738 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Matthew P. Paletta MD 1356756332 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Monica Benedikt MD 1467835249 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Nell Kirst MD 1760619605 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Nicholas Johnson MD 1528441318 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Randall Forsch MD 1013005537 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Randy Forsch MD 1013005537 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Susan Kim MD 1972986768 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Tara Master-Hunter MD 1467541318 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Tyler S. Policht MD 1982019964 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Yujing Lin MD 1750796736 UofM-Chelsea Family Medicine 14700 E Old US Highway 12 Chelsea, MI 48118 Washtenaw Anne Kittendorf MD 1679661672 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Cheryl LaMore MD 1114046570 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Christa Williams MD 1144336975 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Elisa Picken MD 1669591079 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Katherine Hughey MD 1417211640 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Kathryn Harmes MD 1235108523 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Kristi Vander Hyde NP 1225030497 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Michael McKee MD 1578521894 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Michelle Rabideau MD 1528157476 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Phillip Zazove MD 1306935267 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Stephen Wampler MD 1346321064 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Theresa Peters MD 1619066560 UofM-Dexter Family Medicine 7300 Dexter-Ann Arbor Rd. Dexter, MI 48130 Washtenaw Amal Othman MD 1457510349 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Amy Miller MD 1407944994 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Christine Krause MD 1629167655 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw David Alvarez DO 1902994494 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Heather Holmstrom MD 1306940424 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Jill Schneiderhan MD 1306847595 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Joy Williams MD 1770672636 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Julie Prussack MD 1639433865 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Karl Rew MD 1033185079 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Katherine Jo Gold MD 1972691491 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Margaret A. Riley MD 1699894014 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Mary Bieniasz NP 1598771362 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 December 8, 2017 Michigan Department of Health and Human Services Page 28 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Washtenaw Masahito Jimbo MD 1841388378 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Michael Fetters MD 1144318668 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Micheleen Hashikawa MD 1235365743 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Pamela Rockwell DO 1154410009 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Robert Kiningham MD 1346338456 UofM-Domino Farms Family Medicine 24 Frank Lloyd Wright Dr, Lobby H, PO Box 431 Ann Arbor, MI 48106 Washtenaw Ayano Kiyota MD 1700076429 UofM-Livonia Health Center 20321 Farmington Rd. Livonia, MI 48152 Washtenaw Christina Chiang MD 1558657700 UofM-Livonia Health Center 20321 Farmington Rd. Livonia, MI 48152 Washtenaw Christina Nisonger Murphy MD 1497067300 UofM-Livonia Health Center 20321 Farmington Rd. Livonia, MI 48152 Washtenaw Christine Medaugh MD 1972866648 UofM-Livonia Health Center 20321 Farmington Rd. Livonia, MI 48152 Washtenaw Elizabeth K. Jones MD 1033372156 UofM-Livonia Health Center 20321 Farmington Rd. Livonia, MI 48152 Washtenaw Justine Wu MD 1790897379 UofM-Livonia Health Center 20321 Farmington Rd. Livonia, MI 48152 Washtenaw Keturah Schacht MD 1760794671 UofM-Livonia Health Center 20321 Farmington Rd. Livonia, MI 48152 Washtenaw Sahoko Little MD 1811106990 UofM-Livonia Health Center 20321 Farmington Rd. Livonia, MI 48152 Washtenaw Angie Wang MD 1609216795 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Anna K. McEvoy MD 1659786630 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw David Schrock MD 1548643331 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Deborah A. Leech Phipps MD 1306251384 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Jane E. Chargot MD 1881034957 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Jean Wong MD 1164541553 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Joel Heidelbaugh MD 1689762114 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Kaila A. Queen MD 1477936268 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Laura E. A. Heinrich MD 1043650120 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Leigh Morrison MD 1942683735 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Marian E. Deames MD 1891100863 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Matthew K. Kittle DO 1316352396 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Niyati Shah MD 1891136354 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Timothy Tellez MD 1275916074 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Uche George-Nwogu MD 1336237858 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw William E. Chavey MD 1366530867 UofM-Ypsilanti Health Center Family Medicine 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Adrienne Carey MD 1114363256 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Aleksandr Belakovskiy MD 1740663525 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Allison Effron MD 1134565757 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Ashley DeHudy MD 1821433343 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Courtney Palka MD 1346628625 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Elise Gross MD 1568849883 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Elizabeth Hill MD 1952746414 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Emily Graham MD 1457612434 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Emily Hayden MD 1275912438 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Erica Martin MD 1598148389 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Helene Doleyres MD 1821401381 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Jennifer McDonald MD 1598030850 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Jennifer Taylor MD 1831501196 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Kerri Neville MD 1679987572 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Mansoor Arain MD 1649531625 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Margeaux Naughton MD 1124464649 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Morgen Govindan MD 1982017448 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Nicholas Holzemer MD 1386025302 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Sami El-Dalati MD 1336551985 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 Washtenaw Samuel Neher MD 1467831149 UoM Med- Residency Program D3227 MPB, 1500 E. Medical Center Dr. Ann Arbor, MI 48109 December 8, 2017 Michigan Department of Health and Human Services Page 29 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Washtenaw Caroline Richardson MD 1346339298 UoM Med-Ypsilanti Health Center PEDS 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Terence Joiner MD 1174539324 UoM Med-Ypsilanti Health Center PEDS 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Yolaine Civil MD 1013025691 UoM Med-Ypsilanti Health Center PEDS 200 Amet, Suite 200 Ypsilanti, MI 48198 Washtenaw Dr. Jennifer Rimmke MD 1215163779 Ypsilanti Health Center 200 Arnet St. Suite 200 Ypsilanti 48198 Washtenaw Dr. Katherine Freundlich MD 1881915379 Ypsilanti Health Center 200 Arnet St. Suite 200 Ypsilanti 48198 Washtenaw Dr. Layla Mohammed MD 1184630345 Ypsilanti Health Center 200 Arnet St. Suite 200 Ypsilanti 48198 Washtenaw Dr. Chris Benner MD 1659531374 Ypsilanti Pediatrics 645 Morning Glory Lane Milan, 48160 Washtenaw Dr. Courtney Strohacker MD 1689960007 Ypsilanti Pediatrics 1500 East Medical Center Dr D3236 Ann Arbor, MI 48109-5718 Washtenaw Dr. Shaili Rajput MD 1427344829 Ypsilanti Pediatrics 200 Arnet Suite 200 Ann Arbor 48198 Washtenaw Pai C. Meng MD 1073542361 5936 Cedar Ridge Dr. Wayne Alice Kachman MD 1750323432 American Indian Health and Family Services 4880 Lawndale Detroit, MI 48210 Wayne Jossette French MD 1194790071 American Indian Health and Family Services 4880 Lawndale Detroit, MI 48210 Wayne Julie Collins-Marquez NP 1376941047 American Indian Health and Family Services 4880 Lawndale Detroit, MI 48210 Wayne Ayesha M. Taj DO 1801858733 Bader Khan, MD Pediatric Clinic 8528 North Canton Center Rd Canton, MI 48187 Wayne Bader F. Khan MD 1174593966 Bader Khan, MD Pediatric Clinic 8528 North Canton Center Rd Canton, MI 48187 Wayne Chia-wen Lee MD 1891941282 Boriboon Pediatrics 3850 Pelham Dearborn, MI 48124 Wayne Kingkham Boriboon MD 1023103025 Boriboon Pediatrics 3850 Pelham Dearborn, MI 48124 Wayne Dr. Henry Marcus DO 1669473096 Brentwood Pediatrics 33215 7 Mile Rd Livonia 48152 Wayne Baqir Malik MD 1568402022 Canton Center Pediatrics 5958 N. Canton Center Rd # 300 Canton, MI 48187 Wayne Kauser Malik MD 1497816623 Canton Center Pediatrics 5958 N. Canton Center Rd # 300 Canton, MI 48187 Wayne Javita Snyder NP 1457766131 Central City Integrated Health 10 Peterboro Detroit, MI 48201 Wayne Veronica Smith NP 1770991796 Central City Integrated Health 10 Peterboro Detroit, MI 48201 Wayne Jurin Boriboon MD 1336198142 Child and Adolescent Center PC 15350 Trenton Rd, Southgate Mi 48195 Wayne Petronio Yadao MD 1598721722 Child and Adolescent Center PC 15350 Trenton Rd, Southgate Mi 48195 Wayne Khalid Kamal MD 1669448783 Child and Adolescent Center, PC 15350 Trenton Rd Southgate 48195 Wayne Saba Cossor MD 1871796706 Child and Adolescent Center, PC 15350 Trenton Rd Southgate 48195 Wayne Dr. Laura Walls MD 1336272426 Children's Care Medical Center 225 S. Troy Suite 180 Royal Oak 48070 Wayne Dr. Sulafa Roumayah MD 1659362226 Children's Care Medical Center 225 S. Troy Suite 180 Royal Oak 48070 Wayne Raghda Chwikani MD 1134195480 Children's Health Center- Dearborn 10326 West Warren Ave. Dearborn, MI 48126 Wayne Aimee Johnson MD 1437388733 Childrens Hosp of MI- General Pediatrics 3950 Beaubien Detroit, MI 48201 Wayne Marilyn Sarkesian NP 1891814620 Children's Hosp of MI Hamtramak School Based Health 11410 Charest Hamtramck 48212 Center Wayne Dr. Barbara Oettgen MD 1366467227 Children's Hospital of Michigan 3901 Beaubien Detroit 48201 Wayne Dr. Mona Hanna-Attisha MD/Assistant 1265470348 Children's Hospital of Michigan 3901 Beaubien Detroit 48201 Practitioner Wayne Dr. Sri Gandra Pediatrician 1881610533 Children's Hospital of Michigan 3901 Beaubien Detroit 48201 Wayne Dr. Teresa Holtrop MD 1285674762 Children's Hospital of Michigan 3901 Beaubien Detroit 48201 Wayne Cathy Wenz NP 1003102963 Covenant Community Care Inc - Curtis Clinic 16411 Curtis Detroit, MI 48235 Wayne Kai Palm MD 1184853632 Covenant Community Care Inc - Joy Clinic 18917 Joy Rd Detroit, MI 48228 Wayne Nicole Prince MD 1679860142 Covenant Community Care Inc - Joy Clinic 18917 Joy Rd Detroit, MI 48228 Wayne Betsy Cherian MD 1164742110 Covenant Community Care Inc - Michigan Ave Clinic 5716 Michigan Ave Detroit, MI 48210 Wayne Chase Thebault MD 1699920082 Covenant Community Care Inc - Michigan Ave Clinic 5716 Michigan Ave Detroit, MI 48210 Wayne Mary Hakim MD 1518168020 Covenant Community Care Inc - Michigan Ave Clinic 5716 Michigan Ave Detroit, MI 48210 Wayne Scott Stryd MD 1528032174 Covenant Community Care Inc - Michigan Ave Clinic 5716 Michigan Ave Detroit, MI 48210 Wayne Lisa Randon MD 1316088644 Davison Pediatrics 1260 N. Irish Road, Suite A Flint, MI 48423 Wayne Ally Dakroub MD 1003174202 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Amrit Misra MD 1184067423 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Arjun Gowda MD 1487033437 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Cory McFall MD 1336481662 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Daniel Hanba MD 1497142681 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne David Pavkovich MD 1972948313 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Donald Okoye MD 1063866408 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Eric Ayers MD 1407893118 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Erin Miller MD 1922441708 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 December 8, 2017 Michigan Department of Health and Human Services Page 30 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Wayne Gipsa Joseph MD 1013335041 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Gita Gupta MD 1710305842 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Hannah Kwak MD 1992150197 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Heather Abraham MD 1154616985 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Ijeoma Nnodim-Opara MD 1003069766 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Jane Philip MD 1679929020 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Kathryn Rice MD 1245684190 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Khalid Ebrahim MD 1346637634 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Kimberly Herrmann MD 1033537089 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Lamar Johnson MD 1497174270 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Latonya Riddle-Jones MD 1508021536 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Michelle El-Hosni MD 1033596903 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Millicent Traylor MD 1194171496 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Rachel Beredo Marcucci MD 1902167737 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Renato Roxas MD 1124065727 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Shira Heisler MD 1922428150 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Tomas Murphy MD 1568859270 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Yuqing Gao MD 1760837009 Detroit Medical Center/Wayne State University Med-Peds 50 E. Canfield Detroit, MI 48201 Wayne Adam Singer DO 1083078984 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Adeeba Khan MD 1023267317 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Adekunbi A. Adelakun MD 1801240445 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Ahdi Amer MD 1548207145 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Alcesa Backos MD 1740227743 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Alpa Patel Shah DO 1649511387 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Amie Hinshaw MD 1255751012 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Andrea R. Bedway MD 1033563101 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Andrea Reed MD 1386021657 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Anne Mortensen MD 1477591535 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Batool Hussain MD 1942756291 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Brian Pfeiffer DO 1356746697 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Carl Tabb II MD 1982059242 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Cindy Agu DO 1215381975 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Deepak Kamat MD 1174561807 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Diana Torpoco-Rivera MD 1144675364 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Dunya Mohammad MD 1053796409 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Elana Ackerman MD 1033521307 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Hani Siddeek MD 1205255627 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Heather Axelrod DO 1700237500 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Heather Bartlet NP 1194762195 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Hieu Nguyen MD 1306223730 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Hilary Beauchamp MD 1285020263 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Jaclyn Held DO 1730541954 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Jacqueline Larouere DO 1316359854 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Jenie Ferrer DO 1992124861 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Jonathan Heckman DO 1578950283 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Juan Lozano MD 1538588892 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Judith Lau DO 1518311315 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Jyoti Mani MD 1447679824 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Katherine Regling DO 1174940548 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Kenghia Billings MD 1235410580 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne LaShanna Lovell MD 1821417023 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Lauren Snabb MD 1104130012 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Madhav Bandatmakur MD 1467834911 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Marina Migliore DO 1558789669 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 December 8, 2017 Michigan Department of Health and Human Services Page 31 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Wayne Marlisa Wolf MD 1508220062 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Maureen Dewitt MD 1972990943 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Melissa Noronha MD 1154717924 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Michael Woodall MD 1952788747 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Millicent Traylor MD 1194171496 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Mohamed Taki MD 1447604368 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Muhammad Mian MD 1376797522 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Myo Sabai Aye MD 1770979130 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Nancy Knuth NP 1093964678 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Pallavi Karunakaran MD 1184010795 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Prabhumallikarjun Patil MD 1124574009 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Randal Harris MD 1265887582 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Sean Sullivan MD 1932596772 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Sharon Marshall MD 1659319770 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Sri Gandra DO 1881610533 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Tammi Cooks MD 1194112946 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Tania Haddad Abiaad DO 1356790778 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Yamini Jadcherla MD 1154785483 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Yvonne Friday MD 1801833801 DMC Pediatric Residency 3950 Beaubien Detroit, MI 48201 Wayne Fikrat Kayali MD 1669449096 Hamtramck Medical Center 6100 Dorothy Street Detroit, MI 48222 Wayne Louise Aloe MD 1760430466 Hawthorn Center PO Box 530223 Livonia, MI 48153 Wayne Stacey Leatherwood MD 1306993118 Henry Ford Health System 3031 W. Grand Blvd. Suite 800 Detroit, MI 48202 Wayne Mary Leona Serowoky NP 1245237551 Henry Ford Health System, School Based and Community One Ford Place 4C Detroit, MI 49202 Health Program Wayne Van C. Momon MD 1942357751 Henry Ford Medical Center 5500 Auto Club Dr. Suite 160 Dearborn, MI 48126 Wayne Natalie Narzark Stefan MD 1396892105 Henry Ford Medical Center- Ford Rd 5500 Auto Club Dr. Suite 160 Dearborn, MI 48126 Wayne Tisa Johnson-Hooper MD 1134276934 Henry Ford Pediatrics-NCO 3031 W. Grand Blvd. Suite 800 Detroit, MI 48202 Wayne Mary Burton Brooks MD 1033108337 Henry Ford- Sterling Heights 3500 15 Mile Rd Sterling Heights, MI 48310 Wayne Amit Gupta MD 1679991277 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Andrea Smith DO 1114388725 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Bartosz Kaczmarek MD 1831445279 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Berta Rezik MD 1477917466 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Bumsoo Park MD 1376924373 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Diana Ferrans MD 1851469662 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Fanar Alyas MD 1932468097 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Gabriel Okpagu MD 1669890315 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Islam Zineldin MD 1326402256 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Kendra Allen MD 1255759775 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Lilian Ore DO 1861885196 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Maryann Jacob MD 1649665670 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Michelle Ramsay MD 1811315344 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Nada Almasri MD 1346635828 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Nazia Munir MD 1053739797 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Pamela Castro-Camero DO 1518328608 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Rebecca Busk-Sutton DO 1255757985 HFHS - Family Medicine Residency 2799 W Grand Blvd. Detroit, MI 48202-2608 Wayne Daniel Passerman DO 1043366842 HFHS-Harbortown 3370 E. Jefferson Detroit, MI 48207 Wayne Katarzyna Budzynska MD 1396914024 HFHS-Harbortown 3370 E. Jefferson Detroit, MI 48207 Wayne Kimberly Winston-Matthews MD 1033283551 HFHS-Harbortown 3370 E. Jefferson Detroit, MI 48207 Wayne Mariam Costandi MD 1487850509 HFHS-Harbortown 3370 E. Jefferson Detroit, MI 48207 Wayne Melissa Little-Morton NP 1568546372 HFHS-Harbortown 3370 E. Jefferson Detroit, MI 48207 Wayne Raghavendra Vemulapalli MD 1497829915 HFHS-Harbortown 3370 E. Jefferson Detroit, MI 48207 Wayne Rebecca Busk-Sutton DO 1255757985 HFHS-Harbortown 3370 E. Jefferson Detroit, MI 48207 Wayne Ken Strzelecki DO 1851557714 HFHS-New Center One Pediatrics 3031 West Grand Blvd Detroit, MI 48202 December 8, 2017 Michigan Department of Health and Human Services Page 32 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Wayne Lonetta Postell MD 1770826984 HFHS-New Center One Pediatrics 3031 West Grand Blvd Detroit, MI 48202 Wayne Nakia Williams MD 1659556181 HFHS-New Center One Pediatrics 3031 West Grand Blvd Detroit, MI 48202 Wayne Neelima Acharya MD 1760696884 HFHS-New Center One Pediatrics 3031 West Grand Blvd Detroit, MI 48202 Wayne Stacy Leatherwood MD 1306993118 HFHS-New Center One Pediatrics 3031 West Grand Blvd Detroit, MI 48202 Wayne Tisa Johnson-Hooper MD 1134276934 HFHS-New Center One Pediatrics 3031 West Grand Blvd Detroit, MI 48202 Wayne Wenhui Hua MD 1316094113 HFHS-New Center One Pediatrics 3031 West Grand Blvd Detroit, MI 48202 Wayne Kavita Warrier MD 1275630006 IHA Canton Pediatrics Heritage Park 1600 S. Canton Center Road Canton, MI 48188 Wayne Kerry Swanton NP 1780784850 IHA Canton Pediatrics Heritage Park 1600 S. Canton Center Road Canton, MI 48188 Wayne Sarah Lacy MD 1811023617 IHA Canton Pediatrics Heritage Park 1600 S. Canton Center Road Canton, MI 48188 Wayne Bryn K. Genick NP 1386742427 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Christine Victoria MD 1467728618 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Crystal Barrow MD 1144286550 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Judy Tosto MD 1104048115 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Kendrick Owings MD 1336117720 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Kerri Randal MD 1871627786 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Lisa Sprague MD 1053389593 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Madhavi Sennerikuppam MD 1982753950 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Melissa McNier MD 1578531042 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Nancy Anastasi MD 1609844042 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Patricia Reckling NP 1043310618 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Sarah Lacy MD 1811023617 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Tuan Bui MD 1548575764 IHA Pediatric Healthcare Associates, Canton 49650 Cherry Hill Suite 210 Canton, MI 48187 Wayne Dr. Nancy Spangler MD 1396853719 IHA-CHA Plymouth 990 W Ann Arbor Trail Suite 210 Plymouth 48170 Wayne James Landers MD 1225139918 James Landers MD PC DBA Pointe Pediatric Associates 20825 Mack Avenue Suite 4 Grosse Point Woods, MI 48236 Wayne Tonya M. Moss NP 1700189636 Mary Lee Community Health and Training Center 25548 Five Rd Redford, MI 48204 Wayne Mayura Madani MD 1992867204 Mayura Madani, MD PLLC 4727 St Antoine St. Detroit, MI 48201 Wayne LaTanya Boyce NP 1851671879 McAuley Health Center 5555 Conner Ste 2691 Detroit 48213 Wayne Tracey Chan NP 1710091376 McAuley Health Center 5555 Conner Ste 2691 Detroit 48213 Wayne Tracy Threat NP 1891951711 McAuley Health Center 5555 Conner Ste 2691 Detroit 48213 Wayne Muhammad Al-Ado MD 1982792545 Park Pediatrics 8449 Park Ave. Allen Park, MI 48101 Wayne Brooke Nayak NP 1003246380 Pediatric & Adolescent Center 15555 Northline Rd Southgate, MI 48195 Wayne Dinesh Nayak MD 1568430502 Pediatric & Adolescent Center 15555 Northline Rd Southgate, MI 48195 Wayne Kimberly A. Dunleavy NP 1811373384 Pediatric & Adolescent Center 15555 Northline Rd Southgate, MI 48195 Wayne Lakshmi V. Hanasoge MD 1568545077 Pediatric & Adolescent Center 15555 Northline Rd Southgate, MI 48195 Wayne Sandra M. Bronni MD 1548209950 Pediatric & Adolescent Center 15555 Northline Rd Southgate, MI 48195 Wayne Shannon Schwartz NP 1164887675 Pediatric & Adolescent Center 15555 Northline Rd Southgate, MI 48195 Wayne Zeeshan Tarique MD 1770779589 Pediatric & Adolescent Center 15555 Northline Rd Southgate, MI 48195 Wayne Lorette Haddad MD 1265472104 Pediatric and Adolescent Center of Michigan 10645 West Warren, Suite 200 Dearborn, MI 48126 Wayne Jenatta Francis MD 1124381462 Pediatric Associates of Dearborn 2331 Monroe St. Dearborn, MI 48124 Wayne Lakshimi Nulu MD 1902245954 Pediatric Associates of Dearborn 2331 Monroe St. Dearborn, MI 48124 Wayne Leslie Mofrad NP 1508138033 Pediatric Associates of Dearborn 2331 Monroe St. Dearborn, MI 48124 Wayne Linda Chicko NP 1285814574 Pediatric Associates of Dearborn 2331 Monroe St. Dearborn, MI 48124 Wayne Natacha Umlauf-Barrera MD 1245206044 Pediatric Associates of Dearborn 2331 Monroe St. Dearborn, MI 48124 Wayne Dr. William Heath MD 1023033503 Pediatric Staff, Inc. 22341 8 Mile Rd Detroit 48219 Wayne Huey-Fong Liang NP 1093952012 Pediatric Staff, Inc. 22341 8 Mile Rd Detroit 48219 Wayne Henri Godbold MD 1407012834 Professional Medical Centers-Detroit 7 Mile 20901 W. 7 Mile Rd. Detroit, MI 48219 Wayne Temitope Olagbaiye NP 1043561277 Professional Medical Centers-Detroit Mt. Elliot 3956 Mt. Elliot Detroit, MI 48207 Wayne Nazem Alhusein MD 1578543112 River Oaks Medical Center 20211 Ann Arbor Trail Dearborn Heights, MI 48127 Wayne Maimoona Husain MD 1487731816 Sanjay Lakhani MD PC, DBA Highland Park Health Center 13111 Woodward Avenue Highland Park, MI 48203 Wayne Sanjay Lakhani MD 1700962446 Sanjay Lakhani MD PC, DBA Highland Park Health Center 13111 Woodward Avenue Highland Park, MI 48203 Wayne Hiam Nhme MD 1528249224 Shaker Haddad, MD PC 12813 West Warren Avenue Dearborn, MI 48126 Wayne Shaker Haddad MD 1093788069 Shaker Haddad, MD PC 12813 West Warren Avenue Dearborn, MI 48126 Wayne Sapna Brogan MD 1790006187 Southfield Pediatric Physicians 31500 Telegraph Rd. Ste 105 Bingham Farms, MI 48025 Wayne Adam Ploegman DO 1508247156 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 December 8, 2017 Michigan Department of Health and Human Services Page 33 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Wayne Alicia Hall NP 1235421868 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Alina Witkowski MD 1164416863 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Amber Sikorski DO 1306256649 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Aseel Zeidan MD 1942684923 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Basel Hamzeh MD 1790779080 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne BROOKE Blazius DO 1386094548 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Christin Lawrence MD 1912317389 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Christy Petroff MD 1467433516 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne COLLEEN Considine MD 1861842353 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Dhanalakshmi Senniappan MD 1801264098 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Diana Maniev MD 1609280502 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Douglas Ziegler MD 1689668816 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne JENIFER Gehlsen DO 1871943779 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Kaitlin Park DO 1255745634 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Karen Alton MD 1649264037 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Kate Webber NP 1023047594 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Kaylynn Temple DO 1457704926 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne KENDRA Maurer MD 1255781746 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Kristen Lee MD 1932519253 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Lauren Azevedo DO 1639557085 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne LORA Reams DO 1245612399 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Malik Muhammad Anwar Ul MD 1033664487 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Maradith Skalak MD 1760861348 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Mary Dolan DO 1821402405 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Mary MacLeod DO 1679953640 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Monica Du MD 1619383619 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne NATALIE Blum DO 1689024606 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Natalie Kontos DO 1053571885 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Nora Katerji MD 1912389289 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Rand Farjo MD 1477547297 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Rofida Nofal MD 1578979340 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Rohit Kapoor MD 1245616358 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Sage Church DO 1902185598 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Saleem Raza MD 1205874807 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne SHAMA Shirazi MD 1093165128 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Tiffany Chritz DO 1750760070 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Yi-Chun Lai (Jennifer) MD 1780094227 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Wayne Adrienne Aschmetat DO 1801184742 St. Mary's Primary Care-Livonia 14600 Farmington Rd Suite 105 Livonia, MI 48154 Wayne Erin Walton-Doyle MD 1427256460 St. Mary's Primary Care-Livonia 14600 Farmington Rd Suite 105 Livonia, MI 48154 Wayne Mhd-Hussam DiarBakrli MD 1831522655 Taylor Pediatrics 23611 Goddard Rd Taylor, MI 48180 Wayne Dr. Helen Byrd MD 1750394425 Universal Pediatrics 4727 St. Antoine St Ste 404 Detroit, MI 48201 Wayne Dr. Jane Steiger MD 1598979205 Universal Pediatrics 4727 St. Antoine St Ste 404 Detroit, MI 48201 Wayne Dr. Philomina Thomas MD 1851404636 Universal Pediatrics 4727 St. Antoine St Ste 404 Detroit, MI 48201 Wayne Cornelius James MD 1750669438 UofM Med-Northville Health Center 39901 Traditions Drive Northville, MI 48168 Wayne Danielle Akers MD 1932496676 UofM Med-Northville Health Center 39901 Traditions Drive Northville, MI 48168 Wayne David Hanauer MD 1245246289 UofM Med-Northville Health Center 39901 Traditions Drive Northville, MI 48168 Wayne Heba Abu-Isa MD 1184850638 UofM Med-Northville Health Center 39901 Traditions Drive Northville, MI 48168 Wayne Isabel Bender MD 1114213733 UofM Med-Northville Health Center 39901 Traditions Drive Northville, MI 48168 Wayne Jean Seyfried MD 1760496962 UofM Med-Northville Health Center 39901 Traditions Drive Northville, MI 48168 Wayne Jill Lancaster MD 1437185998 UofM Med-Northville Health Center 39901 Traditions Drive Northville, MI 48168 Wayne Latisha Carter-Blanks MD 1700923810 UofM Med-Northville Health Center 39901 Traditions Drive Northville, MI 48168 Wayne Beth Tarini MD 1174620900 UofM-Canton Health Center 1051 N Canton Center Rd. Canton, MI 48187 Wayne Debra Langlois MD 1265433304 UofM-Canton Health Center 1051 N Canton Center Rd. Canton, MI 48187 December 8, 2017 Michigan Department of Health and Human Services Page 34 of 34

Fluoride Varnish Training Certificates for Medicaid Professionals County: Name: Title: Provider NPI: Agency: Address: Wayne Esther Yoon MD 1528130077 UofM-Canton Health Center 1051 N Canton Center Rd. Canton, MI 48187 Wayne Kelly Harte MD 1245315886 UofM-Canton Health Center 1051 N Canton Center Rd. Canton, MI 48187 Wayne Margie Andreae MD 1376559518 UofM-Canton Health Center 1051 N Canton Center Rd. Canton, MI 48187 Wayne Megan Olson MD 1194046318 UofM-Canton Health Center 1051 N Canton Center Rd. Canton, MI 48187 Wayne Amy Kreykes MD 1992069124 UoM Family Medicine Residency 12345 Main Street Ann Arbor, MI 48104 Wayne Deatra Young MD 1528187838 Wayne County Healthy Communities Hamtramck Health 9021 Joseph Campau Hamtramck, MI 48212 Center Wayne George T. Sawabini DO 1699765479 Western Wayne Family Health Centers-Inkster 2700 Hamlin Inkster, MI 48141 Wayne Philip J. Jackson MD 1437174638 Western Wayne Family Health Centers-Inkster 2700 Hamlin Inkster, MI 48141 Wayne Tania T. Sarker MD 1679701692 Western Wayne Family Health Centers-Inkster 2700 Hamlin Inkster, MI 48141 Wayne, Ronald D. Hertz DO 1053304816 St. John Hospital and Medical Center 22201 Moross Rd. Suite 270 Detroit, MI 48236 Macomb Wayne, Alicia Hall CPNP 1235421868 St. John Children's Center 22201 Moross Rd. Suite 70 Detroit, MI 48236 Macomb, Oakland Wayne, Marcus DeGraw MD 1750375002 St. John Children's Center 22201 Moross Rd. PBII Suite 70 Detroit, MI 48236 Macomb, Oakland Wayne, Kate Webber CPNP 1023047594 St. John Hospital 251 Moran Rd. Grosse Point Farms, MI 48236 Macomb, Oakland Wayne, Erin C. Walton-Doyle MD 1427256460 St. Mary Mercy Medical Group 14600 Farmington Rd. Suite 105 Livonia, MI 48154 Oakland, Washtenaw, Macomb Wexford Angela Trucks MD 1457536138 Mackinaw Trail Pediatrics 7917 Mackinaw Trail Cadillac, MI 49601 Wexford Elizabeth Rzepkaalto MD 1033176599 Mackinaw Trail Pediatrics 7917 Mackinaw Trail Cadillac, MI 49601 Wexford Gerald Herring MD 1750348975 Mackinaw Trail Pediatrics 7917 Mackinaw Trail Cadillac, MI 49601 Wexford Joseph Santangelo MD 1952374803 Mackinaw Trail Pediatrics 7917 Mackinaw Trail Cadillac, MI 49601 Wexford Mary Blackmer NP 1861719304 Mackinaw Trail Pediatrics 7917 Mackinaw Trail Cadillac, MI 49601 Wexford Megan Santangelo MD 1376523282 Mackinaw Trail Pediatrics 7917 Mackinaw Trail Cadillac, MI 49601 Wexford Susan Betts-Barbus MD 1437116233 Mackinaw Trail Pediatrics 7917 Mackinaw Trail Cadillac, MI 49601