Provider Demographics
NPI:1104256387
Name:PARK VIEW FAMILY DENTISTRY
Entity type:Organization
Organization Name:PARK VIEW FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-350-6747
Mailing Address - Street 1:202 N LAKE ST
Mailing Address - Street 2:
Mailing Address - City:BOYNE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49712-1210
Mailing Address - Country:US
Mailing Address - Phone:231-582-4480
Mailing Address - Fax:231-582-4460
Practice Address - Street 1:202 N LAKE ST
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712-1210
Practice Address - Country:US
Practice Address - Phone:231-582-4480
Practice Address - Fax:231-582-4460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI22901019425122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901019425OtherSTATE DENTAL LICENSE