Healthcare Provider Details

I. General information

NPI: 1134844871
Provider Name (Legal Business Name): MICHIGAN DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 10/05/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 MICHIGAN STREET OPTIONAL
PORT HURON MI
48060-3811
US

IV. Provider business mailing address

522 MICHIGAN ST. OPTIONAL
PORT HURON MI
48060
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-8711
  • Fax:
Mailing address:
  • Phone: 810-987-8711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDREA ROBBINS MARGEAS
Title or Position: OWNER/DENTIST
Credential:
Phone: 810-987-8711