Healthcare Provider Details

I. General information

NPI: 1609085158
Provider Name (Legal Business Name): GINA MARIE BIERSACK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 N M-37 HIGHWAY SUITE A
MIDDLEVILLE MI
49333
US

IV. Provider business mailing address

4525 N M-37 HIGHWAY SUITE A
MIDDLEVILLE MI
49333
US

V. Phone/Fax

Practice location:
  • Phone: 269-795-4400
  • Fax: 269-795-9670
Mailing address:
  • Phone: 269-795-4400
  • Fax: 269-795-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901019378
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2025968
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901019378
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: