Provider Demographics
NPI:1669649026
Name:BLUE WATER DENTAL GROUP PORT HURON P.C.
Entity Type:Organization
Organization Name:BLUE WATER DENTAL GROUP PORT HURON P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUANN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-987-7224
Mailing Address - Street 1:803 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3764
Mailing Address - Country:US
Mailing Address - Phone:810-987-7224
Mailing Address - Fax:810-987-8585
Practice Address - Street 1:803 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3764
Practice Address - Country:US
Practice Address - Phone:810-987-7224
Practice Address - Fax:810-987-8585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI105021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty