Healthcare Provider Details

I. General information

NPI: 1033630975
Provider Name (Legal Business Name): MICHIGAN DENTAL ASSOCIATES - LANSING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 S PENNSYLVANIA AVE
LANSING MI
48910-1897
US

IV. Provider business mailing address

999 PEACHTREE ST NE STE 800
ATLANTA GA
30309-4425
US

V. Phone/Fax

Practice location:
  • Phone: 734-234-6040
  • Fax:
Mailing address:
  • Phone: 404-537-5211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901013819
License Number StateMI

VIII. Authorized Official

Name: MARTHA J HARP
Title or Position: DIRECTOR OF INSURANCE OPERATIONS
Credential:
Phone: 678-372-7358