Provider Demographics
NPI:1003191941
Name:GREAT LAKES FAMILY DENTAL GROUP DEXTER, PC
Entity Type:Organization
Organization Name:GREAT LAKES FAMILY DENTAL GROUP DEXTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-625-2860
Mailing Address - Street 1:3060 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MI
Mailing Address - Zip Code:48130-1140
Mailing Address - Country:US
Mailing Address - Phone:734-426-4651
Mailing Address - Fax:
Practice Address - Street 1:3060 BAKER RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-1140
Practice Address - Country:US
Practice Address - Phone:734-426-4651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty