Healthcare Provider Details

I. General information

NPI: 1376124552
Provider Name (Legal Business Name): JATIVA FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 W MICHIGAN AVE
CLINTON MI
49236-9577
US

IV. Provider business mailing address

PO BOX 549
CLINTON MI
49236-0549
US

V. Phone/Fax

Practice location:
  • Phone: 517-456-7471
  • Fax:
Mailing address:
  • Phone: 517-456-7471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARCY SOSKO
Title or Position: FRONT OFFICE
Credential:
Phone: 517-456-7471