Provider Demographics
NPI:1518307768
Name:ST. CHARLES FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ST. CHARLES FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SEARLS-ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-712-4772
Mailing Address - Street 1:1117 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-4920
Mailing Address - Country:US
Mailing Address - Phone:517-712-4772
Mailing Address - Fax:
Practice Address - Street 1:228 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MI
Practice Address - Zip Code:48655-1429
Practice Address - Country:US
Practice Address - Phone:989-865-6731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010199931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty