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General NPI Number Information
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NPI Number | 1679212369
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Entity Type | Organization
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Legal Business Name | INDEPENDENCE DENTAL
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Dates
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Enumeration Date | 06/01/2022
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Last Update Date | 06/01/2022
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Provider Practice Location Address
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Address Line | 717 S GRAND AVE
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City | FOWLERVILLE
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State | MI
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Zip | 48836-7914
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Country | US
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Telephone | 517-223-9753
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 158
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City | FOWLERVILLE
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State | MI
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Zip | 48836-0158
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Country | US
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Telephone | 517-223-9753
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHRISTOPHER STINES
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Credential | DDS
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Telephone | 517-223-9753
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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