Provider Demographics
NPI:1639791585
Name:PGS D-PROVIDER DENTISTRY PLLC
Entity Type:Organization
Organization Name:PGS D-PROVIDER DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-727-3815
Mailing Address - Street 1:1616 GRATIOT BLVD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-1181
Mailing Address - Country:US
Mailing Address - Phone:586-727-3815
Mailing Address - Fax:
Practice Address - Street 1:1616 GRATIOT BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-1181
Practice Address - Country:US
Practice Address - Phone:586-727-3815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PGS D-PROVIDER DENTISTRY PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty