Provider Demographics
NPI:1629265293
Name:NORTHERN DENTAL GROUP, PC
Entity Type:Organization
Organization Name:NORTHERN DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREATMENT COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-539-8467
Mailing Address - Street 1:P.O. BOX 275
Mailing Address - Street 2:421 STIMPSON ST.
Mailing Address - City:PELLSTON
Mailing Address - State:MI
Mailing Address - Zip Code:49769-0275
Mailing Address - Country:US
Mailing Address - Phone:231-539-8467
Mailing Address - Fax:231-539-8466
Practice Address - Street 1:421 STIMPSON ST.
Practice Address - Street 2:
Practice Address - City:PELLSTON
Practice Address - State:MI
Practice Address - Zip Code:49769-0275
Practice Address - Country:US
Practice Address - Phone:231-539-8467
Practice Address - Fax:231-539-8466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010-16726122300000X
MI29010-17732122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty