MEDICARE: RACINE & ACKLEY D.D.S., P.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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1760851794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RACINE & ACKLEY D.D.S., P.C.

Provider Business Mailing Address
First Line	:	573 W VIENNA ST
Second Line	:
City	:	CLIO
State	:	MI
Zip	:	48420-5000
Country	:	US
Telephone Number	:	810-686-5220
Fax Number	:	810-686-1620

Provider Business Practice Location Address
First Line	:	573 W VIENNA ST
Second Line	:
City	:	CLIO
State	:	MI
Zip	:	48420-5000
Country	:	US
Telephone Number	:	810-686-5220
Fax Number	:	810-686-1620

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. PAUL JOSEPH RACINE
Credential	:	D.D.S.
Telephone Number	:	810-686-5220

Provider Enumeration Date	:	09/21/2015
Last Update Date	:	09/21/2015

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1558739375 — PAMELA HOPKINS AGNP
Practice Location Address:

4154 W VIENNA RD # 3
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Practice Location Address:

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