MEDICARE: GRAND TRAVERSE DENTAL CARE, 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	2901016153	MI

General Provider Information

NPI Number	:	1518930932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND TRAVERSE DENTAL CARE, PC

Provider Business Mailing Address
First Line	:	1087 BUSINESS PARK DR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-8372
Country	:	US
Telephone Number	:	231-935-1599
Fax Number	:	231-935-1922

Provider Business Practice Location Address
First Line	:	1087 BUSINESS PARK DR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-8372
Country	:	US
Telephone Number	:	231-935-1599
Fax Number	:	231-935-1922

Authorized Official
Title or Position	:	CEO
Name	:	DR. THOMAS C. SALON
Credential	:	D.D.S.
Telephone Number	:	231-935-1599

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	08/22/2020

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