MEDICARE: CENTRAL MICHIGAN FAMILY DENTISTRY, 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1568109726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL MICHIGAN FAMILY DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	1110 E BROOMFIELD ST
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-4437
Country	:	US
Telephone Number	:	989-772-4581
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 E BROOMFIELD ST
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-4437
Country	:	US
Telephone Number	:	989-772-4581
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DERREK HENRIE
Credential	:	DDS
Telephone Number	:	989-772-4581

Provider Enumeration Date	:	05/18/2022
Last Update Date	:	05/25/2022

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