Provider Demographics
NPI:1396837431
Name:GREAT LAKES FAMILY DENTAL GROUP - BAY CITY PC
Entity Type:Organization
Organization Name:GREAT LAKES FAMILY DENTAL GROUP - BAY CITY 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:810-732-0200
Mailing Address - Street 1:1012 LAFAYETTE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708
Mailing Address - Country:US
Mailing Address - Phone:989-893-5711
Mailing Address - Fax:
Practice Address - Street 1:1012 LAFAYETTE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708
Practice Address - Country:US
Practice Address - Phone:989-893-5711
Practice Address - Fax:989-893-5854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty