Provider Demographics
NPI:1285310128
Name:BUBBLE GUM KIDS DENTISTRY
Entity type:Organization
Organization Name:BUBBLE GUM KIDS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT OF OPERATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUNDLAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-400-9999
Mailing Address - Street 1:460
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-984-5437
Mailing Address - Fax:810-987-9499
Practice Address - Street 1:460
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-984-5437
Practice Address - Fax:810-987-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty