Provider Demographics
NPI:1093966640
Name:CHARLES F. LYDY, D.D.S., P.C.
Entity Type:Organization
Organization Name:CHARLES F. LYDY, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:LYDY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-790-0700
Mailing Address - Street 1:144 N FROST DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-7186
Mailing Address - Country:US
Mailing Address - Phone:989-790-0700
Mailing Address - Fax:989-790-7411
Practice Address - Street 1:144 N FROST DR
Practice Address - Street 2:SUITE 1
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48638-7186
Practice Address - Country:US
Practice Address - Phone:989-790-0700
Practice Address - Fax:989-790-7411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4053826Medicaid