Provider Demographics
NPI:1760153720
Name:BDD OF MICHIGAN P.C.
Entity Type:Organization
Organization Name:BDD OF MICHIGAN P.C.
Other - Org Name:DERKSEN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-776-9642
Mailing Address - Street 1:PO BOX 8250
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60197-8250
Mailing Address - Country:US
Mailing Address - Phone:517-394-4040
Mailing Address - Fax:
Practice Address - Street 1:2410 LAKE LANSING RD STE 2
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3659
Practice Address - Country:US
Practice Address - Phone:517-371-5342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BDD OF MICHIGAN PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-21
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty