=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386919660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETTMAN & BETTMAN FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2012
-----------------------------------------------------
Last Update Date | 03/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2909 E GRAND RIVER AVE STE 212
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48912-4335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-485-1769
-----------------------------------------------------
Fax | 517-482-7440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2909 E GRAND RIVER AVE STE 212
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48912-4335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-485-1769
-----------------------------------------------------
Fax | 517-482-7440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | ROBERT GEORGE BETTMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-485-1769
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901013418
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------