Provider Demographics
NPI:1033370341
Name:GREAT LAKES FAMILY DENTAL GROUP-ALMONT,P.C.
Entity Type:Organization
Organization Name:GREAT LAKES FAMILY DENTAL GROUP-ALMONT,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE MANAGER
Authorized Official - Prefix:MRS
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 1:606 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALMONT
Mailing Address - State:MI
Mailing Address - Zip Code:48003-8553
Mailing Address - Country:US
Mailing Address - Phone:810-798-8585
Mailing Address - Fax:
Practice Address - Street 1:606 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALMONT
Practice Address - State:MI
Practice Address - Zip Code:48003-8553
Practice Address - Country:US
Practice Address - Phone:810-798-8585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2-ORGANIZATIONOtherDENTAL GROUP