=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003903741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWAY AND HALL ORTHODONTICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12776 S WEST BAY SHORE DR
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-5451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-946-0070
-----------------------------------------------------
Fax | 231-946-6026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12776 S WEST BAY SHORE DR
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-5451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-946-0070
-----------------------------------------------------
Fax | 231-946-6026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANANGER
-----------------------------------------------------
Name | MRS. LISA CROUCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-946-0070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------