Provider Demographics
NPI:1558801720
Name:LARRY WARECK
Entity Type:Organization
Organization Name:LARRY WARECK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:WIFE
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARECK
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:231-276-9051
Mailing Address - Street 1:2120 M 137 # 95
Mailing Address - Street 2:
Mailing Address - City:INTERLOCHEN
Mailing Address - State:MI
Mailing Address - Zip Code:49643-9386
Mailing Address - Country:US
Mailing Address - Phone:231-276-9051
Mailing Address - Fax:
Practice Address - Street 1:2120 M 137 # 95
Practice Address - Street 2:
Practice Address - City:INTERLOCHEN
Practice Address - State:MI
Practice Address - Zip Code:49643-9386
Practice Address - Country:US
Practice Address - Phone:231-276-9051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901013338122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty