Provider Demographics
NPI:1346500279
Name:GWENDOLYN BUCK DDS PLLC
Entity Type:Organization
Organization Name:GWENDOLYN BUCK DDS PLLC
Other - Org Name:NORTHERN TRAILS DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-346-6349
Mailing Address - Street 1:271 E STATE HIGHWAY M35
Mailing Address - Street 2:PO BOX 309
Mailing Address - City:GWINN
Mailing Address - State:MI
Mailing Address - Zip Code:49841-9003
Mailing Address - Country:US
Mailing Address - Phone:906-346-6349
Mailing Address - Fax:
Practice Address - Street 1:271 E STATE HIGHWAY M35
Practice Address - Street 2:
Practice Address - City:GWINN
Practice Address - State:MI
Practice Address - Zip Code:49841-9003
Practice Address - Country:US
Practice Address - Phone:906-346-6349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010197511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty