Healthcare Provider Details

I. General information

NPI: 1629265293
Provider Name (Legal Business Name): NORTHERN DENTAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 STIMPSON ST.
PELLSTON MI
49769-0275
US

IV. Provider business mailing address

P.O. BOX 275 421 STIMPSON ST.
PELLSTON MI
49769-0275
US

V. Phone/Fax

Practice location:
  • Phone: 231-539-8467
  • Fax: 231-539-8466
Mailing address:
  • Phone: 231-539-8467
  • Fax: 231-539-8466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number29010-17732
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number29010-16726
License Number StateMI

VIII. Authorized Official

Name: MRS. PATRICIA ANN SOPER
Title or Position: TREATMENT COORDINATOR
Credential:
Phone: 231-539-8467