Provider Demographics
NPI:1134220593
Name:HOUGHTON LAKE DENTAL GROUP, PC
Entity type:Organization
Organization Name:HOUGHTON LAKE DENTAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-366-9621
Mailing Address - Street 1:3185 W HOUGHTON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48629-8242
Mailing Address - Country:US
Mailing Address - Phone:989-366-9621
Mailing Address - Fax:989-366-8237
Practice Address - Street 1:3185 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629-8242
Practice Address - Country:US
Practice Address - Phone:989-366-9621
Practice Address - Fax:989-366-8237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI179971223G0001X
MI178951223G0001X
MI87791223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4393541Medicaid
MI4393523Medicaid