MEDICARE: GREAT LAKES FAMILY DENTAL GROUP - MT MORRIS PC

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

General Provider Information

NPI Number	:	1326130469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES FAMILY DENTAL GROUP - MT MORRIS PC

Provider Business Mailing Address
First Line	:	8326 N SAGINAW STREET
Second Line	:
City	:	MT MORRIS
State	:	MI
Zip	:	48458
Country	:	US
Telephone Number	:	810-687-5040
Fax Number	:	810-687-5130

Provider Business Practice Location Address
First Line	:	8326 N SAGINAW STREET
Second Line	:
City	:	MT MORRIS
State	:	MI
Zip	:	48458
Country	:	US
Telephone Number	:	810-687-5040
Fax Number	:	810-687-5130

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MRS. PATRICIA J HART
Credential	:
Telephone Number	:	810-238-6260

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	08/22/2020

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