Provider Demographics
NPI:1992204952
Name:MID MICHIGAN DENTAL IMPLANT CENTER, PC
Entity Type:Organization
Organization Name:MID MICHIGAN DENTAL IMPLANT CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DOCKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PC
Authorized Official - Phone:866-438-6464
Mailing Address - Street 1:800 N STATE ST STE 151
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48888-9708
Mailing Address - Country:US
Mailing Address - Phone:866-438-6464
Mailing Address - Fax:989-831-9020
Practice Address - Street 1:800 N STATE ST STE 151
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:MI
Practice Address - Zip Code:48888-9708
Practice Address - Country:US
Practice Address - Phone:866-438-6464
Practice Address - Fax:989-831-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901013734122300000X
MI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty