Provider Demographics
NPI:1598160483
Name:FERRIS STATE UNIVERSITY
Entity Type:Organization
Organization Name:FERRIS STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEALANT COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREITAG
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:231-591-3130
Mailing Address - Street 1:200 FERRIS DR
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2740
Mailing Address - Country:US
Mailing Address - Phone:231-591-3130
Mailing Address - Fax:
Practice Address - Street 1:200 FERRIS DR
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2740
Practice Address - Country:US
Practice Address - Phone:231-591-3130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018836122300000X
MI2902011248124Q00000X
MI2902002544124Q00000X
MI2902004089124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty