Healthcare Provider Details

I. General information

NPI: 1518307768
Provider Name (Legal Business Name): ST. CHARLES FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 S SAGINAW ST
SAINT CHARLES MI
48655-1429
US

IV. Provider business mailing address

1117 RIVERSIDE DR
OWOSSO MI
48867-4920
US

V. Phone/Fax

Practice location:
  • Phone: 989-865-6731
  • Fax:
Mailing address:
  • Phone: 517-712-4772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901019993
License Number StateMI

VIII. Authorized Official

Name: DR. JESSICA D SEARLS-ELLIOTT
Title or Position: DENTIST
Credential:
Phone: 517-712-4772