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General NPI Number Information
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NPI Number | 1790569622
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Entity Type | Organization
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Legal Business Name | MARK J LODGE
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Dates
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Enumeration Date | 08/22/2023
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Last Update Date | 08/22/2023
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Provider Practice Location Address
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Address Line | 134 HIGH ST
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City | GRAND BLANC
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State | MI
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Zip | 48439-1335
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Country | US
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Telephone | 810-694-8073
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Fax | 810-694-1764
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Provider Business Mailing Address
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Address Line | 134 HIGH ST
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City | GRAND BLANC
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State | MI
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Zip | 48439-1335
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Country | US
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Telephone | 810-694-8073
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Fax | 810-694-1764
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. SANDRA SMITH
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Credential |
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Telephone | 810-694-8073
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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