Provider Demographics
NPI:1013074095
Name:WESTNEDGE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:WESTNEDGE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:SACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-345-8893
Mailing Address - Street 1:3907 S WESTNEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-3187
Mailing Address - Country:US
Mailing Address - Phone:269-345-8893
Mailing Address - Fax:269-492-1710
Practice Address - Street 1:3907 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-3187
Practice Address - Country:US
Practice Address - Phone:269-345-8893
Practice Address - Fax:269-492-1710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI147411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI16115OtherMI DELTA DENTAL # JUNGBLU
MI3273360Medicaid
MI17761OtherMASON-DELTA DENTAL MI
MI2901016115OtherTIM JUNGBLUT STATE LICENS
MI2901017761OtherLICENSE #
MI2901014741OtherLICENSE
MI14741OtherSACKETT-DELTA DENTAL #
MI3273324Medicaid
MI2901017761OtherLICENSE #
MI486361Medicare UPIN
MI796159Medicare UPIN
MI4172952Medicare ID - Type UnspecifiedMEDICAID #-DR MASON