Provider Demographics
NPI:1972530178
Name:PFOTENHAUER, RICHARD CHARLES (DDS, PC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CHARLES
Last Name:PFOTENHAUER
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 N 9TH ST
Mailing Address - Street 2:STE B
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-1660
Mailing Address - Country:US
Mailing Address - Phone:906-428-1325
Mailing Address - Fax:
Practice Address - Street 1:823 DELTA AVE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837-1646
Practice Address - Country:US
Practice Address - Phone:906-428-1325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901013893122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383575211OtherEMPLOYER IDENTIFICATION N