Healthcare Provider Details

I. General information

NPI: 1730276411
Provider Name (Legal Business Name): TOOTH TIME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7057 STONEY CREEK DR
AUGUSTA MI
49012-8883
US

IV. Provider business mailing address

7057 STONEY CREEK DR
AUGUSTA MI
49012-8883
US

V. Phone/Fax

Practice location:
  • Phone: 269-731-4581
  • Fax:
Mailing address:
  • Phone: 269-731-4581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number2901017274
License Number StateMI

VIII. Authorized Official

Name: DOLLIE M BLACK
Title or Position: DIRECTOR
Credential: RDH
Phone: 269-731-4581