MEDICARE: MRS. SUSAN L SHORE-VIGNOLA D.D.S.

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	2901014317	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	:	1952394439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN L SHORE-VIGNOLA D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 719
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651-0719
Country	:	US
Telephone Number	:	231-839-2630
Fax Number	:	231-839-5751

Provider Business Practice Location Address
First Line	:	213 S CANAL ST
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651-7929
Country	:	US
Telephone Number	:	231-839-2630
Fax Number	:	231-839-5751

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	05/03/2016

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