Provider Demographics
NPI:1396148342
Name:PAW PAW FAMILY DENTISTRY, PLC.
Entity type:Organization
Organization Name:PAW PAW FAMILY DENTISTRY, PLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-657-4001
Mailing Address - Street 1:32800 E RED ARROW HWY
Mailing Address - Street 2:PO BOX 232
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-9401
Mailing Address - Country:US
Mailing Address - Phone:269-251-2286
Mailing Address - Fax:
Practice Address - Street 1:32800 E RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-9401
Practice Address - Country:US
Practice Address - Phone:269-251-2286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019821122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty