1558410902 NPI number — GREGORY DAVID LA FAYETTE DDS

Table of content: GREGORY DAVID LA FAYETTE DDS (NPI 1558410902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558410902 NPI number — GREGORY DAVID LA FAYETTE DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LA FAYETTE
Provider First Name:
GREGORY
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1558410902
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 N LAKE ST
Provider Second Line Business Mailing Address:
LOWER LEVEL
Provider Business Mailing Address City Name:
MANISTIQUE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49854-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-341-6132
Provider Business Mailing Address Fax Number:
906-341-3054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 N LAKE ST
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
MANISTIQUE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49854-1234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-341-6132
Provider Business Practice Location Address Fax Number:
906-341-3054
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2901016294 , 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: 2952112 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: D802465 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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