=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699051888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT LAKES FAMILY DENTAL GROUP SAGINAW, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2011
-----------------------------------------------------
Last Update Date | 11/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 427 N. MICHIGAN AVENUE
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-755-0991
-----------------------------------------------------
Fax | 989-755-0001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | G3222 BEECHER RD
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48532-3614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-230-3245
-----------------------------------------------------
Fax | 810-230-3229
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE MANAGER
-----------------------------------------------------
Name | PATRICIA J. HART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 810-625-2860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------