Provider Demographics
NPI:1275685265
Name:NORTHERN MICHIGAN PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:NORTHERN MICHIGAN PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAN WINGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-947-4566
Mailing Address - Street 1:4944 SKYVIEW CT
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7173
Mailing Address - Country:US
Mailing Address - Phone:231-947-4566
Mailing Address - Fax:
Practice Address - Street 1:4944 SKYVIEW CT
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7173
Practice Address - Country:US
Practice Address - Phone:231-947-4566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017484261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4457700OtherMEDICAID
MID158620OtherBLUE CROSS BLUE SHIELD MI