Provider Demographics
NPI:1053484253
Name:OSHTEMO FAMILY DENTISTRY, PC
Entity Type:Organization
Organization Name:OSHTEMO FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:BANNOW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-372-1042
Mailing Address - Street 1:5917 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3017
Mailing Address - Country:US
Mailing Address - Phone:269-372-1042
Mailing Address - Fax:269-372-9962
Practice Address - Street 1:5917 STADIUM DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-3017
Practice Address - Country:US
Practice Address - Phone:269-372-1042
Practice Address - Fax:269-372-9962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012099122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty