1790215028 NPI number — CASEVILLE FAMILY DENTISTRY, PC

Table of content: (NPI 1790215028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790215028 NPI number — CASEVILLE FAMILY DENTISTRY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CASEVILLE FAMILY DENTISTRY, 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:
1790215028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 279
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48725-0279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-856-4096
Provider Business Mailing Address Fax Number:
989-856-4025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6982 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48725-5110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-856-4096
Provider Business Practice Location Address Fax Number:
989-856-4025
Provider Enumeration Date:
06/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
REDWANTZ
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
989-856-4096

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  15627 , 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: 15627 . This is a "STATE DENTAL LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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