Provider Demographics
NPI:1609033406
Name:MICHIGAN DENTURE & IMPLANT CENTER PC
Entity Type:Organization
Organization Name:MICHIGAN DENTURE & IMPLANT CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:VERNIER
Authorized Official - Suffix:
Authorized Official - Credentials:D D S
Authorized Official - Phone:586-779-6777
Mailing Address - Street 1:22855 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2057
Mailing Address - Country:US
Mailing Address - Phone:586-779-6777
Mailing Address - Fax:586-779-0926
Practice Address - Street 1:22855 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2057
Practice Address - Country:US
Practice Address - Phone:586-779-6777
Practice Address - Fax:586-779-0926
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHIGAN DENTURE & IMPLANT CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI800328OtherBCBS