Healthcare Provider Details

I. General information

NPI: 1164170577
Provider Name (Legal Business Name): HOLY FAMILY DENTAL CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 E MAIN ST
HARTFORD MI
49057-1120
US

IV. Provider business mailing address

301 N CENTER ST
HARTFORD MI
49057-1199
US

V. Phone/Fax

Practice location:
  • Phone: 269-621-0011
  • Fax: 269-308-3336
Mailing address:
  • Phone: 269-621-0011
  • Fax: 269-308-3336

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: DR. DONNIE D BOUCHARD
Title or Position: PRESIDENT
Credential: DO
Phone: 269-621-0011