Healthcare Provider Details

I. General information

NPI: 1558801720
Provider Name (Legal Business Name): LARRY WARECK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 M 137 # 95
INTERLOCHEN MI
49643-9386
US

IV. Provider business mailing address

2120 M 137 # 95
INTERLOCHEN MI
49643-9386
US

V. Phone/Fax

Practice location:
  • Phone: 231-276-9051
  • Fax:
Mailing address:
  • Phone: 231-276-9051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901013338
License Number StateMI

VIII. Authorized Official

Name: RENEE WARECK
Title or Position: WIFE
Credential: MANAGER
Phone: 231-276-9051