MEDICARE: DR. TARYN LEE GLADWISH 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	2901600817	MI
2	1223G0001X	General Practice Dentistry	2901600817	MI

General Provider Information

NPI Number	:	1427678283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TARYN LEE GLADWISH D.D.S

Provider Business Mailing Address
First Line	:	64845 VAN DYKE RD STE 3
Second Line	:
City	:	WASHINGTON
State	:	MI
Zip	:	48095-2836
Country	:	US
Telephone Number	:	586-752-6596
Fax Number	:

Provider Business Practice Location Address
First Line	:	64845 VAN DYKE RD STE 3
Second Line	:
City	:	WASHINGTON
State	:	MI
Zip	:	48095-2836
Country	:	US
Telephone Number	:	586-752-6596
Fax Number	:

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

Provider Enumeration Date	:	04/22/2020
Last Update Date	:	07/03/2021

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