MEDICARE: MIDWEST FAMILY DENTAL CARE PORTAGE PC

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

General Provider Information

NPI Number	:	1902782592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST FAMILY DENTAL CARE PORTAGE PC

Provider Business Mailing Address
First Line	:	706 W CENTRE AVE
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-5310
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	706 W CENTRE AVE
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-5310
Country	:	US
Telephone Number	:	269-323-1679
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	PAIGE COCHRAN
Credential	:
Telephone Number	:	269-355-6072

Provider Enumeration Date	:	08/12/2025
Last Update Date	:	08/12/2025

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