Provider Demographics
NPI:1063640480
Name:COPPER COUNTRY FAMILY DENTISTRY P.C.
Entity Type:Organization
Organization Name:COPPER COUNTRY FAMILY DENTISTRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:CHALGREN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-482-0808
Mailing Address - Street 1:19225 CALVERLEY ST
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-2809
Mailing Address - Country:US
Mailing Address - Phone:906-482-0808
Mailing Address - Fax:906-482-0808
Practice Address - Street 1:19225 CALVERLEY ST
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-2809
Practice Address - Country:US
Practice Address - Phone:906-482-0808
Practice Address - Fax:906-482-0808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-24
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010200421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty