Provider Demographics
NPI:1548422264
Name:EVERGREEN DENTAL CENTER,PLLC
Entity Type:Organization
Organization Name:EVERGREEN DENTAL CENTER,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:W
Authorized Official - Last Name:HARTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-484-5811
Mailing Address - Street 1:2805 E MOUNT HOPE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-1916
Mailing Address - Country:US
Mailing Address - Phone:517-484-5811
Mailing Address - Fax:517-484-5873
Practice Address - Street 1:2805 E MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-1916
Practice Address - Country:US
Practice Address - Phone:517-484-5811
Practice Address - Fax:517-484-5873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty