Provider Demographics
NPI:1780861484
Name:PERIODONTAL SPECIALISTS OF GRAND BLANC PC
Entity Type:Organization
Organization Name:PERIODONTAL SPECIALISTS OF GRAND BLANC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE ASST.
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:COGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-695-6444
Mailing Address - Street 1:8185 HOLLY RD
Mailing Address - Street 2:SUITE19
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2444
Mailing Address - Country:US
Mailing Address - Phone:810-695-6444
Mailing Address - Fax:
Practice Address - Street 1:8185 HOLLY RD
Practice Address - Street 2:SUITE19
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2444
Practice Address - Country:US
Practice Address - Phone:810-695-6444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI169091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty