Provider Demographics
NPI:1437323904
Name:MID-MICHIGAN PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:MID-MICHIGAN PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SUSHYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:810-733-5310
Mailing Address - Street 1:1125 S LINDEN RD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4073
Mailing Address - Country:US
Mailing Address - Phone:810-733-5310
Mailing Address - Fax:810-733-1216
Practice Address - Street 1:1125 S LINDEN RD
Practice Address - Street 2:SUITE 800
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4073
Practice Address - Country:US
Practice Address - Phone:810-733-5310
Practice Address - Fax:810-733-1216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2014-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010199601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4060491Medicaid