Provider Demographics
NPI:1811414931
Name:DOWAGIAC FAMILY DENTISTRY, PC
Entity Type:Organization
Organization Name:DOWAGIAC FAMILY DENTISTRY, PC
Other - Org Name:DOWAGIAC FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:GILLESBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-782-5161
Mailing Address - Street 1:530 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DOWAGIAC
Mailing Address - State:MI
Mailing Address - Zip Code:49047-2101
Mailing Address - Country:US
Mailing Address - Phone:269-782-5161
Mailing Address - Fax:269-782-1126
Practice Address - Street 1:530 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-2101
Practice Address - Country:US
Practice Address - Phone:269-782-5161
Practice Address - Fax:269-782-1126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017899261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental