Provider Demographics
NPI:1215100987
Name:NORTHERN MICHIGAN FAMILY DENTISTRY PLLC
Entity type:Organization
Organization Name:NORTHERN MICHIGAN FAMILY DENTISTRY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOENIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-732-4199
Mailing Address - Street 1:PO BOX 1725
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49734-5725
Mailing Address - Country:US
Mailing Address - Phone:989-732-4199
Mailing Address - Fax:989-731-6762
Practice Address - Street 1:1507 S OTSEGO AVE STE A
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9524
Practice Address - Country:US
Practice Address - Phone:989-732-4199
Practice Address - Fax:989-731-6762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI160801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty