Provider Demographics
NPI:1104947878
Name:MID-MICHIGAN DENTAL ASSOCIATES PLC GLADWIN
Entity type:Organization
Organization Name:MID-MICHIGAN DENTAL ASSOCIATES PLC GLADWIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CONEY
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:989-426-6341
Mailing Address - Street 1:200 W CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-2020
Mailing Address - Country:US
Mailing Address - Phone:989-426-6341
Mailing Address - Fax:989-426-6411
Practice Address - Street 1:200 W CEDAR AVE
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-2020
Practice Address - Country:US
Practice Address - Phone:989-426-6341
Practice Address - Fax:989-426-6411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI019185122300000X
MI015374122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty