MEDICARE: OLD MISSION PENINSULA DENTISTRY RC

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	2901019846	MI

General Provider Information

NPI Number	:	1497117923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLD MISSION PENINSULA DENTISTRY RC

Provider Business Mailing Address
First Line	:	3258 BOWERS HARBOR RD
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-9737
Country	:	US
Telephone Number	:	231-223-4232
Fax Number	:	231-223-9205

Provider Business Practice Location Address
First Line	:	3258 BOWERS HARBOR RD
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-9737
Country	:	US
Telephone Number	:	231-223-4232
Fax Number	:	231-223-9205

Authorized Official
Title or Position	:	OWNER
Name	:	MELISSA AYLWORTH
Credential	:
Telephone Number	:	231-223-4232

Provider Enumeration Date	:	03/23/2016
Last Update Date	:	03/28/2016

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