MEDICARE: TOOTH TIME

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	1223D0001X	Public Health Dentistry	2901017274	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730276411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOOTH TIME

Provider Business Mailing Address
First Line	:	7057 STONEY CREEK DR
Second Line	:
City	:	AUGUSTA
State	:	MI
Zip	:	49012-8883
Country	:	US
Telephone Number	:	269-731-4581
Fax Number	:

Provider Business Practice Location Address
First Line	:	7057 STONEY CREEK DR
Second Line	:
City	:	AUGUSTA
State	:	MI
Zip	:	49012-8883
Country	:	US
Telephone Number	:	269-731-4581
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DOLLIE M BLACK
Credential	:	RDH
Telephone Number	:	269-731-4581

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	08/22/2020

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Directions to “TOOTH TIME ” Practice Location

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