Provider Demographics
NPI:1578786034
Name:LENAWEE DENTAL CLINIC INC
Entity Type:Organization
Organization Name:LENAWEE DENTAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT BOARD OF DIRECTORS
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-263-9022
Mailing Address - Street 1:128 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-2723
Mailing Address - Country:US
Mailing Address - Phone:517-266-0651
Mailing Address - Fax:517-266-8476
Practice Address - Street 1:128 S BROAD ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2723
Practice Address - Country:US
Practice Address - Phone:517-266-0651
Practice Address - Fax:517-266-8476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:2007-04-23
Deactivation Code:
Reactivation Date:2007-04-30
Provider Licenses
StateLicense IDTaxonomies
MI188691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty