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General NPI Number Information
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NPI Number | 1215100987
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Entity Type | Organization
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Legal Business Name | NORTHERN MICHIGAN FAMILY DENTISTRY PLLC
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Dates
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Enumeration Date | 04/02/2008
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Last Update Date | 03/19/2018
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Provider Practice Location Address
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Address Line | 1507 S OTSEGO AVE STE A
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City | GAYLORD
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State | MI
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Zip | 49735-9524
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Country | US
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Telephone | 989-732-4199
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Fax | 989-731-6762
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Provider Business Mailing Address
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Address Line | PO BOX 1725
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City | GAYLORD
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State | MI
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Zip | 49734-5725
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Country | US
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Telephone | 989-732-4199
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Fax | 989-731-6762
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | NICOLE KOENIG
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Credential |
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Telephone | 989-732-4199
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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 | 16080
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License Number State | MI
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