Provider Demographics
NPI:1245283340
Name:EGGLESTON FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:EGGLESTON FAMILY DENTISTRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:HARRISON
Authorized Official - Last Name:EGGLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-682-0147
Mailing Address - Street 1:4649 N BRETON CT SE
Mailing Address - Street 2:#B
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5211
Mailing Address - Country:US
Mailing Address - Phone:616-682-0147
Mailing Address - Fax:
Practice Address - Street 1:4649 N BRETON CT SE
Practice Address - Street 2:#B
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5211
Practice Address - Country:US
Practice Address - Phone:616-682-0147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010159861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty