Provider Demographics
NPI:1386835999
Name:GREAT LAKES FAMILY DENTAL GROUP BLISSFIELD PC
Entity Type:Organization
Organization Name:GREAT LAKES FAMILY DENTAL GROUP BLISSFIELD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-625-2860
Mailing Address - Street 1:9178 E US 223
Mailing Address - Street 2:
Mailing Address - City:BLISSFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49228
Mailing Address - Country:US
Mailing Address - Phone:517-486-2030
Mailing Address - Fax:517-486-4414
Practice Address - Street 1:9178 E US 223
Practice Address - Street 2:GREAT LAKES FAMILY DENTAL GROUP BLISSFIELD PC
Practice Address - City:BLISSFIELD
Practice Address - State:MI
Practice Address - Zip Code:49228
Practice Address - Country:US
Practice Address - Phone:517-486-2030
Practice Address - Fax:517-486-4414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty