Provider Demographics
NPI:1316084379
Name:KACY FAMILY DENTISTRY, PC
Entity type:Organization
Organization Name:KACY FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:KACY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-879-2980
Mailing Address - Street 1:77 W SQUARE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2929
Mailing Address - Country:US
Mailing Address - Phone:248-879-2980
Mailing Address - Fax:248-879-2983
Practice Address - Street 1:77 W SQUARE LAKE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-2929
Practice Address - Country:US
Practice Address - Phone:248-879-2980
Practice Address - Fax:248-879-2983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010179981223G0001X
MI29010110721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty