1629265293 NPI number — NORTHERN DENTAL GROUP, PC

Table of content: (NPI 1629265293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629265293 NPI number — NORTHERN DENTAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN DENTAL GROUP, 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:
1629265293
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 275
Provider Second Line Business Mailing Address:
421 STIMPSON ST.
Provider Business Mailing Address City Name:
PELLSTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49769-0275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-539-8467
Provider Business Mailing Address Fax Number:
231-539-8466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
421 STIMPSON ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PELLSTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49769-0275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-539-8467
Provider Business Practice Location Address Fax Number:
231-539-8466
Provider Enumeration Date:
09/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SOPER
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
TREATMENT COORDINATOR
Authorized Official Telephone Number:
231-539-8467

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  29010-16726 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 29010-17732 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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