1245363837 NPI number — MESICK DENTAL CENTER, PC

Table of content: (NPI 1245363837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245363837 NPI number — MESICK DENTAL CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MESICK DENTAL CENTER, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245363837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 489
Provider Second Line Business Mailing Address:
5055 N M-37
Provider Business Mailing Address City Name:
MESICK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49668-0489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-885-1711
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5055 N M 37
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESICK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49668-9705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-885-1711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CAIN
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
231-885-1711

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  2901016563 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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