Provider Demographics
NPI:1740233915
Name:IMLAY CITY DENTAL, P.L.L.C.
Entity type:Organization
Organization Name:IMLAY CITY DENTAL, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-724-8080
Mailing Address - Street 1:216 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-1322
Mailing Address - Country:US
Mailing Address - Phone:810-724-8080
Mailing Address - Fax:810-724-3309
Practice Address - Street 1:216 E 3RD ST
Practice Address - Street 2:
Practice Address - City:IMLAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48444-1322
Practice Address - Country:US
Practice Address - Phone:810-724-8080
Practice Address - Fax:810-724-3309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID8005751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty