Provider Demographics
NPI:1255063244
Name:PEDIATRIC DENTAL SPECILAIST, P.C
Entity type:Organization
Organization Name:PEDIATRIC DENTAL SPECILAIST, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:KACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOODWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-987-5040
Mailing Address - Street 1:1026 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3748
Mailing Address - Country:US
Mailing Address - Phone:810-987-5040
Mailing Address - Fax:810-987-9499
Practice Address - Street 1:1026 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3748
Practice Address - Country:US
Practice Address - Phone:810-987-5040
Practice Address - Fax:810-987-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-28
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4032586Medicaid