Healthcare Provider Details

I. General information

NPI: 1972530178
Provider Name (Legal Business Name): RICHARD CHARLES PFOTENHAUER D.D.S., P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 DELTA AVE
GLADSTONE MI
49837-1646
US

IV. Provider business mailing address

116 N 9TH ST STE B
GLADSTONE MI
49837-1660
US

V. Phone/Fax

Practice location:
  • Phone: 906-428-1325
  • Fax:
Mailing address:
  • Phone: 906-428-1325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901013893
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: