Healthcare Provider Details

I. General information

NPI: 1376152504
Provider Name (Legal Business Name): MICHIGAN DENTISTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2641 SHIRLEY DR
JACKSON MI
49201-8633
US

IV. Provider business mailing address

2641 SHIRLEY DR
JACKSON MI
49201-8633
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-5367
  • Fax:
Mailing address:
  • Phone: 517-787-5367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: CHERYL NOTTEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 517-787-5367