Healthcare Provider Details

I. General information

NPI: 1467667790
Provider Name (Legal Business Name): ORTHODONTIC SPECIALISTS OF MID-MICHIGAN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 CHARLEVOIX DRIVE STE, C
GRAND LEDGE MI
48837
US

IV. Provider business mailing address

1040 CHARLEVOIX DRIVE STE C
GRAND LEDGE MI
48837
US

V. Phone/Fax

Practice location:
  • Phone: 517-627-7600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER HUDSON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 517-627-7600