Provider Demographics
NPI:1669604484
Name:STATE STREET FAMILY DENTAL
Entity type:Organization
Organization Name:STATE STREET FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-227-1858
Mailing Address - Street 1:100 S SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-9038
Mailing Address - Country:US
Mailing Address - Phone:989-227-1858
Mailing Address - Fax:989-227-2268
Practice Address - Street 1:100 S SCOTT RD
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-9038
Practice Address - Country:US
Practice Address - Phone:989-227-1858
Practice Address - Fax:989-227-2268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI901013605122300000X
MI2901018410122300000X
MI012271122300000X
MI2901019279122300000X
MI13188122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty