Provider Demographics
NPI:1316206113
Name:MAIN STREET DENTISTRY, PC
Entity Type:Organization
Organization Name:MAIN STREET DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEYNA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BEHNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-387-4746
Mailing Address - Street 1:210 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YALE
Mailing Address - State:MI
Mailing Address - Zip Code:48097-3319
Mailing Address - Country:US
Mailing Address - Phone:810-387-4746
Mailing Address - Fax:
Practice Address - Street 1:210 S MAIN ST
Practice Address - Street 2:
Practice Address - City:YALE
Practice Address - State:MI
Practice Address - Zip Code:48097-3319
Practice Address - Country:US
Practice Address - Phone:810-387-4746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019511122300000X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty