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General NPI Number Information
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NPI Number | 1134599251
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Entity Type | Organization
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Legal Business Name | BEACON DENTAL CENTER GAYLORD
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Dates
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Enumeration Date | 10/01/2015
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Last Update Date | 10/01/2015
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Provider Practice Location Address
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Address Line | 1723 W M 32 BUILDING B
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City | GAYLORD
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State | MI
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Zip | 49735-9544
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Country | US
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Telephone | 989-448-2802
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Fax | 231-547-5077
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Provider Business Mailing Address
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Address Line | 6483 M 66 N
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City | CHARLEVOIX
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State | MI
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Zip | 49720-9272
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Country | US
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Telephone | 231-547-9141
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Fax | 231-547-5077
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Authorized Official
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Title or Position | OWNER / DOCTOR
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Name | DR. MICHAEL A SULLIVAN
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Credential | DDS
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Telephone | 231-547-9141
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 13522
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 19909
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License Number State | MI
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