1104256387 NPI number — PARK VIEW FAMILY DENTISTRY

Table of content: (NPI 1104256387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104256387 NPI number — PARK VIEW FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARK VIEW FAMILY DENTISTRY
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:
1104256387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 N LAKE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOYNE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49712-1210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-582-4480
Provider Business Mailing Address Fax Number:
231-582-4460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 N LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOYNE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49712-1210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-582-4480
Provider Business Practice Location Address Fax Number:
231-582-4460
Provider Enumeration Date:
11/25/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LARSON
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
PRESIDENT / OWNER
Authorized Official Telephone Number:
231-350-6747

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  22901019425 , 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)

  • Identifier: 2901019425 . This is a "STATE DENTAL LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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