MEDICARE: SPRING ARBOR DENTAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	19622	MI
2	1223G0001X	General Practice Dentistry	21829	MI

General Provider Information

NPI Number	:	1407390107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRING ARBOR DENTAL PLLC

Provider Business Mailing Address
First Line	:	2532 SPRING ARBOR RD
Second Line	:	UNIT 4
City	:	JACKSON
State	:	MI
Zip	:	49203-3663
Country	:	US
Telephone Number	:	517-789-8622
Fax Number	:	517-789-8636

Provider Business Practice Location Address
First Line	:	2532 SPRING ARBOR RD
Second Line	:	UNIT 4
City	:	JACKSON
State	:	MI
Zip	:	49203-3663
Country	:	US
Telephone Number	:	517-789-8622
Fax Number	:	517-789-8636

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MRS. SHERRI L JENNINGS
Credential	:
Telephone Number	:	517-789-8622

Provider Enumeration Date	:	12/14/2016
Last Update Date	:	12/14/2016

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