Provider Demographics
NPI:1790854354
Name:MACK, VINCENT PETER (DDS)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:PETER
Last Name:MACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3347 S AIRPORT RD W
Mailing Address - Street 2:STE D
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-929-7737
Mailing Address - Fax:231-929-4366
Practice Address - Street 1:3347 S AIRPORT RD W
Practice Address - Street 2:STE D
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-929-7737
Practice Address - Fax:231-929-4366
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010147271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice