MEDICARE: IMLAY CITY DENTAL, P.L.L.C.

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	D800575	MI

General Provider Information

NPI Number	:	1740233915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMLAY CITY DENTAL, P.L.L.C.

Provider Business Mailing Address
First Line	:	216 E 3RD ST
Second Line	:
City	:	IMLAY CITY
State	:	MI
Zip	:	48444-1322
Country	:	US
Telephone Number	:	810-724-8080
Fax Number	:	810-724-3309

Provider Business Practice Location Address
First Line	:	216 E 3RD ST
Second Line	:
City	:	IMLAY CITY
State	:	MI
Zip	:	48444-1322
Country	:	US
Telephone Number	:	810-724-8080
Fax Number	:	810-724-3309

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. HENRY D. NICHOLS
Credential	:	D.D.S.
Telephone Number	:	810-724-8080

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	08/22/2020

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