MEDICARE: KNUDSEN DENTISTRY, P.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2901017052	MI
2	1223G0001X	General Practice Dentistry	2901009431	MI
3	1223G0001X	General Practice Dentistry	2901016706	MI

General Provider Information

NPI Number	:	1023061538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KNUDSEN DENTISTRY, P.L.C.

Provider Business Mailing Address
First Line	:	1830 LUDINGTON ST
Second Line	:
City	:	ESCANABA
State	:	MI
Zip	:	49829-2739
Country	:	US
Telephone Number	:	906-786-3936
Fax Number	:

Provider Business Practice Location Address
First Line	:	1830 LUDINGTON ST
Second Line	:
City	:	ESCANABA
State	:	MI
Zip	:	49829-2739
Country	:	US
Telephone Number	:	906-786-3936
Fax Number	:

Authorized Official
Title or Position	:	MEMBER, KNUDSEN DENTISTRY, PLC
Name	:	DR. ERIC WILLIAM KNUDSEN
Credential	:	D.D.S.
Telephone Number	:	906-786-3936

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	08/22/2020

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