Provider Demographics
NPI:1679631923
Name:BOYNE CITY DENTAL
Entity Type:Organization
Organization Name:BOYNE CITY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:REX
Authorized Official - Last Name:MORIARITY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-582-8000
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:830 STATE ST
Mailing Address - City:BOYNE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49712
Mailing Address - Country:US
Mailing Address - Phone:231-582-6644
Mailing Address - Fax:231-582-6853
Practice Address - Street 1:830 STATE ST
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712
Practice Address - Country:US
Practice Address - Phone:231-582-6644
Practice Address - Fax:231-582-6853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901013182122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty