Provider Demographics
NPI:1093980955
Name:MANISTIQUE DENTAL CENTER, P.C.
Entity Type:Organization
Organization Name:MANISTIQUE DENTAL CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LAFAYETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-341-6132
Mailing Address - Street 1:115 N LAKE ST LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-1234
Mailing Address - Country:US
Mailing Address - Phone:906-341-6132
Mailing Address - Fax:906-341-3054
Practice Address - Street 1:115 N LAKE ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-1234
Practice Address - Country:US
Practice Address - Phone:906-341-6132
Practice Address - Fax:906-341-3054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016294122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1558410902Medicaid