Provider Demographics
NPI:1093819344
Name:ACCESS DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:ACCESS DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-8461
Mailing Address - Street 1:431 MUNSON AVE STE C
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3060
Mailing Address - Country:US
Mailing Address - Phone:231-935-8461
Mailing Address - Fax:231-935-8467
Practice Address - Street 1:431 MUNSON AVE STE C
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3060
Practice Address - Country:US
Practice Address - Phone:231-935-8461
Practice Address - Fax:231-935-8467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0128131223G0001X
MI0128651223G0001X
MI0149021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID80295OtherBCBS OF MS
PA823434OtherUNITED CONCORDIA
MID802395OtherBCBS OF MI