MEDICARE: DR. RICHARD CHARLES PFOTENHAUER 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	122300000X	Dentist	2901013893	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	383575211	OTHER	MI	EMPLOYER IDENTIFICATION N

General Provider Information

NPI Number	:	1972530178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD CHARLES PFOTENHAUER D.D.S., P.C.

Provider Business Mailing Address
First Line	:	116 N 9TH ST
Second Line	:	STE B
City	:	GLADSTONE
State	:	MI
Zip	:	49837-1660
Country	:	US
Telephone Number	:	906-428-1325
Fax Number	:

Provider Business Practice Location Address
First Line	:	823 DELTA AVE
Second Line	:
City	:	GLADSTONE
State	:	MI
Zip	:	49837-1646
Country	:	US
Telephone Number	:	906-428-1325
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	09/20/2016

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