Provider Demographics
NPI:1376152504
Name:MICHIGAN DENTISTS PLLC
Entity Type:Organization
Organization Name:MICHIGAN DENTISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:NOTTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-787-5367
Mailing Address - Street 1:2641 SHIRLEY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-8633
Mailing Address - Country:US
Mailing Address - Phone:517-787-5367
Mailing Address - Fax:
Practice Address - Street 1:2641 SHIRLEY DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-8633
Practice Address - Country:US
Practice Address - Phone:517-787-5367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-23
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1295090611OtherEDWIN KWON
MI1518251230OtherANISH GUPTA
MI1952617284OtherFIRAS BELBEISI