Provider Demographics
NPI:1437428364
Name:NORTHERN MICHIGAN FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:NORTHERN MICHIGAN FAMILY DENTISTRY PLLC
Other - Org Name:CHEBOYGAN FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOENIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-732-4199
Mailing Address - Street 1:PO BOX 5215
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-5215
Mailing Address - Country:US
Mailing Address - Phone:316-279-3522
Mailing Address - Fax:
Practice Address - Street 1:10711 N STRAITS HWY
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-9077
Practice Address - Country:US
Practice Address - Phone:231-627-9352
Practice Address - Fax:231-627-9411
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN MICHIGAN FAMILY DENTISTRY PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-21
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI17226122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty