Provider Demographics
NPI:1003479833
Name:MODERN FAMILY DENTAL PC
Entity Type:Organization
Organization Name:MODERN FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HEISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-865-6945
Mailing Address - Street 1:17272 ROBBINS RD STE 104
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2677
Mailing Address - Country:US
Mailing Address - Phone:616-820-5744
Mailing Address - Fax:
Practice Address - Street 1:17272 ROBBINS RD STE 104
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2677
Practice Address - Country:US
Practice Address - Phone:616-820-5744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty