Provider Demographics
NPI:1497117923
Name:OLD MISSION PENINSULA DENTISTRY RC
Entity Type:Organization
Organization Name:OLD MISSION PENINSULA DENTISTRY RC
Other - Org Name:OLD MISSION DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:AYLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-223-4232
Mailing Address - Street 1:3258 BOWERS HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-9737
Mailing Address - Country:US
Mailing Address - Phone:231-223-4232
Mailing Address - Fax:231-223-9205
Practice Address - Street 1:3258 BOWERS HARBOR RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-9737
Practice Address - Country:US
Practice Address - Phone:231-223-4232
Practice Address - Fax:231-223-9205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019846122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty