1821165499 NPI number — FOUR SEASONS DENTAL ASSOCIATES PLLC

Table of content: (NPI 1821165499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821165499 NPI number — FOUR SEASONS DENTAL ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR SEASONS DENTAL ASSOCIATES PLLC
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:
1821165499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 589
Provider Second Line Business Mailing Address:
301 MAIN ST
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49651-0589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-839-4673
Provider Business Mailing Address Fax Number:
231-839-7874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49651-0589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-839-4673
Provider Business Practice Location Address Fax Number:
231-839-7874
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUSHON
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
E
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
231-839-4673

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8011320 . This is a "BCBS OF MICHIGAN" identifier . This identifiers is of the category "OTHER".




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