MEDICARE: DR. GARY PETER HUTNIK D.D.S.

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	122300000X	Dentist	13468	MI

General Provider Information

NPI Number	:	1144200643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY PETER HUTNIK D.D.S.

Provider Business Mailing Address
First Line	:	155 ROWE AVE
Second Line	:
City	:	PORTLAND
State	:	MI
Zip	:	48875-1645
Country	:	US
Telephone Number	:	517-647-6205
Fax Number	:	517-647-5374

Provider Business Practice Location Address
First Line	:	155 ROWE AVE
Second Line	:
City	:	PORTLAND
State	:	MI
Zip	:	48875-1645
Country	:	US
Telephone Number	:	517-647-6205
Fax Number	:	517-647-5374

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	08/02/2007

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