Provider Demographics
NPI:1578002812
Name:MICHIGAN PERIODONTICS GROUP LLC
Entity Type:Organization
Organization Name:MICHIGAN PERIODONTICS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ETHERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-780-6879
Mailing Address - Street 1:350 NORTH MAIN STREET SUITE 110
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118
Mailing Address - Country:US
Mailing Address - Phone:734-719-2700
Mailing Address - Fax:
Practice Address - Street 1:350 N MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1486
Practice Address - Country:US
Practice Address - Phone:734-719-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010210831223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty