Provider Demographics
NPI:1073676466
Name:FIRST DENTAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:FIRST DENTAL MANAGEMENT CORPORATION
Other - Org Name:BRILLIANT SMILES DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-263-3400
Mailing Address - Street 1:113 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-2072
Mailing Address - Country:US
Mailing Address - Phone:517-263-3400
Mailing Address - Fax:517-263-4027
Practice Address - Street 1:113 W FRONT ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2072
Practice Address - Country:US
Practice Address - Phone:517-263-3400
Practice Address - Fax:517-263-4027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010167091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty