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General NPI Number Information
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NPI Number | 1093980955
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Entity Type | Organization
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Legal Business Name | MANISTIQUE DENTAL CENTER, P.C.
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Dates
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Enumeration Date | 04/22/2008
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Last Update Date | 04/22/2008
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Provider Practice Location Address
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Address Line | 115 N LAKE ST LOWR LEVEL
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City | MANISTIQUE
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State | MI
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Zip | 49854-1234
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Country | US
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Telephone | 906-341-6132
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Fax | 906-341-3054
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Provider Business Mailing Address
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Address Line | 115 N LAKE ST LOWR LEVEL
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City | MANISTIQUE
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State | MI
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Zip | 49854-1234
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Country | US
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Telephone | 906-341-6132
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Fax | 906-341-3054
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Authorized Official
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Title or Position | PRESIDENT
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Name | GREGORY DAVID LAFAYETTE
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Credential | DDS
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Telephone | 906-341-6132
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901016294
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License Number State | MI
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