MEDICARE: GREAT LAKES FAMILY DENTAL GROUP-WARREN, P.C.

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	122300000X	Dentist

General Provider Information

NPI Number	:	1801345061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES FAMILY DENTAL GROUP-WARREN, P.C.

Provider Business Mailing Address
First Line	:	G3222 BEECHER RD
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48532-3614
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21635 RYAN RD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48091-2788
Country	:	US
Telephone Number	:	810-230-2345
Fax Number	:	810-230-3229

Authorized Official
Title or Position	:	CORPORATE MANAGER
Name	:	MRS. PATRICIA J. HART
Credential	:
Telephone Number	:	810-625-2860

Provider Enumeration Date	:	09/29/2016
Last Update Date	:	09/29/2016

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