Healthcare Provider Details

I. General information

NPI: 1922575901
Provider Name (Legal Business Name): YALE MAIN STREET DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S MAIN ST
YALE MI
48097-3319
US

IV. Provider business mailing address

6962 LAKEPORT DR
LAKEPORT MI
48059-2209
US

V. Phone/Fax

Practice location:
  • Phone: 810-387-4746
  • Fax:
Mailing address:
  • Phone: 810-545-8215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY PARROTT
Title or Position: MEMBER
Credential: DDS
Phone: 248-875-7269