Provider Demographics
NPI:1376124552
Name:JATIVA FAMILY DENTAL
Entity Type:Organization
Organization Name:JATIVA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOSKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-456-7471
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MI
Mailing Address - Zip Code:49236-0549
Mailing Address - Country:US
Mailing Address - Phone:517-456-7471
Mailing Address - Fax:
Practice Address - Street 1:147 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MI
Practice Address - Zip Code:49236-9577
Practice Address - Country:US
Practice Address - Phone:517-456-7471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental