Provider Demographics
NPI:1649664269
Name:DAWN AG KULONGOWSKI, DDS, PC
Entity type:Organization
Organization Name:DAWN AG KULONGOWSKI, DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-634-1976
Mailing Address - Street 1:124 N SAGINAW ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-1687
Mailing Address - Country:US
Mailing Address - Phone:248-634-1976
Mailing Address - Fax:248-634-2414
Practice Address - Street 1:124 N SAGINAW ST
Practice Address - Street 2:SUITE C
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-1687
Practice Address - Country:US
Practice Address - Phone:248-634-1976
Practice Address - Fax:248-634-2414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010183881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty