Provider Demographics
NPI:1851358873
Name:BAY MILLS INDIAN COMMUNITY
Entity Type:Organization
Organization Name:BAY MILLS INDIAN COMMUNITY
Other - Org Name:BAY MILLS DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ABBY
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUNISTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-248-8315
Mailing Address - Street 1:12455 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:BRIMLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49715-9327
Mailing Address - Country:US
Mailing Address - Phone:906-248-5527
Mailing Address - Fax:906-248-2572
Practice Address - Street 1:12455 W LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:BRIMLEY
Practice Address - State:MI
Practice Address - Zip Code:49715-9327
Practice Address - Country:US
Practice Address - Phone:906-248-5527
Practice Address - Fax:906-248-5765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
MIOA76020261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID171380OtherBLUE CROSS BLUE SHIELD
MI744621656Medicaid
88111OtherDELTA DENTAL
MI00D802025OtherBLUE SHIELD
MI743490175Medicaid