Provider Demographics
NPI:1790569622
Name:MARK J LODGE
Entity Type:Organization
Organization Name:MARK J LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-694-8073
Mailing Address - Street 1:134 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1335
Mailing Address - Country:US
Mailing Address - Phone:810-694-8073
Mailing Address - Fax:810-694-1764
Practice Address - Street 1:134 HIGH ST
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1335
Practice Address - Country:US
Practice Address - Phone:810-694-8073
Practice Address - Fax:810-694-1764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty