Provider Demographics
NPI:1134599251
Name:BEACON DENTAL CENTER GAYLORD
Entity type:Organization
Organization Name:BEACON DENTAL CENTER GAYLORD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-547-9141
Mailing Address - Street 1:6483 M 66 N
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-9272
Mailing Address - Country:US
Mailing Address - Phone:231-547-9141
Mailing Address - Fax:231-547-5077
Practice Address - Street 1:1723 W M 32
Practice Address - Street 2:BUILDING B
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9544
Practice Address - Country:US
Practice Address - Phone:989-448-2802
Practice Address - Fax:231-547-5077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI135221223G0001X
MI199091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty