Provider Demographics
NPI:1194817734
Name:WEST MILHAM DENTAL PROF PC
Entity Type:Organization
Organization Name:WEST MILHAM DENTAL PROF PC
Other - Org Name:MARY ANN BUKOWSKI DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BUKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-381-0564
Mailing Address - Street 1:1416 W MILHAM
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-2245
Mailing Address - Country:US
Mailing Address - Phone:269-381-0564
Mailing Address - Fax:269-381-4965
Practice Address - Street 1:1416 W MILHAM
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-2245
Practice Address - Country:US
Practice Address - Phone:269-381-0564
Practice Address - Fax:269-381-4965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901011980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty