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General NPI Number Information
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NPI Number | 1912572124
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Entity Type | Organization
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Legal Business Name | LAKE CITY FAMILY DENTISTRY
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Dates
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Enumeration Date | 05/21/2021
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Last Update Date | 05/21/2021
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Provider Practice Location Address
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Address Line | 213 S CANAL ST
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City | LAKE CITY
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State | MI
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Zip | 49651-8865
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Country | US
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Telephone | 231-839-2630
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Fax | 231-839-5751
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Provider Business Mailing Address
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Address Line | 213 S CANAL ST PO BOX 719
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City | LAKE CITY
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State | MI
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Zip | 49651
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Country | US
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Telephone | 231-839-2630
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Fax | 231-839-5751
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. MITCH TY CARPENTER-THOMPSON
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Credential | DMD
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Telephone | 231-839-2630
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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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