MEDICARE: TRU DENTAL MICHIGAN 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	:	1326623075
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRU DENTAL MICHIGAN PC

Provider Business Mailing Address
First Line	:	105 HIGHLAND AVE STE 2
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49015-3266
Country	:	US
Telephone Number	:	269-964-3957
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 HIGHLAND AVE STE 2
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49015-3266
Country	:	US
Telephone Number	:	269-964-3957
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	TABATHA LEMKE
Credential	:
Telephone Number	:	217-540-6078

Provider Enumeration Date	:	03/15/2021
Last Update Date	:	03/15/2021

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