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General NPI Number Information
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NPI Number | 1578002812
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Entity Type | Organization
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Legal Business Name | MICHIGAN PERIODONTICS GROUP LLC
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Dates
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Enumeration Date | 02/20/2017
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Last Update Date | 02/20/2017
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Provider Practice Location Address
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Address Line | 350 N MAIN ST STE 110
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City | CHELSEA
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State | MI
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Zip | 48118-1486
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Country | US
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Telephone | 734-719-2700
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Fax |
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Provider Business Mailing Address
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Address Line | 350 NORTH MAIN STREET SUITE 110
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City | CHELSEA
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State | MI
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Zip | 48118
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Country | US
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Telephone | 734-719-2700
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Fax |
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Authorized Official
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Title or Position | REGIONAL MANAGER
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Name | SHAWN MICHAEL ETHERTON
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Credential |
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Telephone | 616-780-6879
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 2901021083
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License Number State | MI
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