Provider Demographics
NPI:1477531457
Name:WEST BAY DENTAL PC
Entity Type:Organization
Organization Name:WEST BAY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-686-5410
Mailing Address - Street 1:401 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-3205
Mailing Address - Country:US
Mailing Address - Phone:989-686-5410
Mailing Address - Fax:989-686-7340
Practice Address - Street 1:401 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-3205
Practice Address - Country:US
Practice Address - Phone:989-686-5410
Practice Address - Fax:989-686-7340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI119811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI817452OtherUCCI PROVIDER NUMBER
MI800527OtherBCBSM PROVIDER NUMBER