MEDICARE: HOUGHTON LAKE FAMILY DENTISTRY

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1235755224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUGHTON LAKE FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	9260 W LAKE CITY RD
Second Line	:
City	:	HOUGHTON LAKE
State	:	MI
Zip	:	48629-8902
Country	:	US
Telephone Number	:	989-422-4099
Fax Number	:	989-422-3167

Provider Business Practice Location Address
First Line	:	9260 W LAKE CITY RD
Second Line	:
City	:	HOUGHTON LAKE
State	:	MI
Zip	:	48629-8902
Country	:	US
Telephone Number	:	989-422-4099
Fax Number	:	989-422-3167

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. ROBERT M PACELLA
Credential	:	DDS
Telephone Number	:	989-422-4099

Provider Enumeration Date	:	06/25/2020
Last Update Date	:	06/25/2020

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