Provider Demographics
NPI:1336171800
Name:TRAVERSE DENTAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:TRAVERSE DENTAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAZZOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-657-1854
Mailing Address - Street 1:555 SOUTH GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3423
Mailing Address - Country:US
Mailing Address - Phone:231-947-0210
Mailing Address - Fax:231-947-6770
Practice Address - Street 1:555 SOUTH GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3423
Practice Address - Country:US
Practice Address - Phone:231-947-0210
Practice Address - Fax:231-947-6770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI121271223G0001X
MI125161223G0001X
MI138331223G0001X
MI29010191221223G0001X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION51680Medicare ID - Type Unspecified