Provider Demographics
NPI:1720271554
Name:KALAMAZOO COUNTY GOVERNMENT DENTAL CLINIC
Entity Type:Organization
Organization Name:KALAMAZOO COUNTY GOVERNMENT DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HOMNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-373-5261
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:MI
Mailing Address - Zip Code:49074-0042
Mailing Address - Country:US
Mailing Address - Phone:269-373-5200
Mailing Address - Fax:269-373-5363
Practice Address - Street 1:3299 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1281
Practice Address - Country:US
Practice Address - Phone:269-373-5259
Practice Address - Fax:269-373-5292
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF KALAMAZOO HEALTH & COMMUNITY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-24
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare