Healthcare Provider Details

I. General information

NPI: 1316206113
Provider Name (Legal Business Name): MAIN STREET DENTISTRY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S MAIN ST
YALE MI
48097-3319
US

IV. Provider business mailing address

210 S MAIN ST
YALE MI
48097-3319
US

V. Phone/Fax

Practice location:
  • Phone: 810-387-4746
  • Fax:
Mailing address:
  • Phone: 810-387-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901019511
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2901019511
License Number StateMI

VIII. Authorized Official

Name: DR. KEYNA LEE BEHNAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 810-387-4746