Healthcare Provider Details

I. General information

NPI: 1326130469
Provider Name (Legal Business Name): GREAT LAKES FAMILY DENTAL GROUP - MT MORRIS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8326 N SAGINAW STREET
MT MORRIS MI
48458
US

IV. Provider business mailing address

8326 N SAGINAW STREET
MT MORRIS MI
48458
US

V. Phone/Fax

Practice location:
  • Phone: 810-687-5040
  • Fax: 810-687-5130
Mailing address:
  • Phone: 810-687-5040
  • Fax: 810-687-5130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. PATRICIA J HART
Title or Position: GENERAL MANAGER
Credential:
Phone: 810-238-6260