MEDICARE: GLDE, PLLC

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	:	1427698851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLDE, PLLC

Provider Business Mailing Address
First Line	:	5978 HARVEY ST
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49444-6720
Country	:	US
Telephone Number	:	231-799-0404
Fax Number	:	231-799-0014

Provider Business Practice Location Address
First Line	:	5978 HARVEY ST
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49444-6720
Country	:	US
Telephone Number	:	231-799-0404
Fax Number	:	231-799-0014

Authorized Official
Title or Position	:	PRAC ADMIN
Name	:	MS. MARY BETH HEGEDUS
Credential	:
Telephone Number	:	231-799-0404

Provider Enumeration Date	:	01/14/2020
Last Update Date	:	01/14/2020

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