=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548870629
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRANK G. RADTKE D.D.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2020
-----------------------------------------------------
Last Update Date | 08/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2128 W VIENNA RD
-----------------------------------------------------
City | CLIO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48420-2128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-686-8870
-----------------------------------------------------
Fax | 810-686-6833
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 39
-----------------------------------------------------
City | CLIO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48420-0039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-686-8870
-----------------------------------------------------
Fax | 810-686-6833
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | PATRICIA BRINDLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 810-686-8870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------