Provider Demographics
NPI:1114101318
Name:SAULT DENTAL ASSOCIATION
Entity Type:Organization
Organization Name:SAULT DENTAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHUNK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-635-6020
Mailing Address - Street 1:709 JOHNSTON ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783
Mailing Address - Country:US
Mailing Address - Phone:906-635-6020
Mailing Address - Fax:906-635-7687
Practice Address - Street 1:709 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-2335
Practice Address - Country:US
Practice Address - Phone:906-635-6020
Practice Address - Fax:906-635-7687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010143201223G0001X
MI29010106271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty