Provider Demographics
NPI:1316139637
Name:HARCHICK, MARY ANN (DDSPC)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:HARCHICK
Suffix:
Gender:F
Credentials:DDSPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 PONTIAC LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328
Mailing Address - Country:US
Mailing Address - Phone:248-682-2050
Mailing Address - Fax:248-618-3742
Practice Address - Street 1:4204 PONTIAC LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328
Practice Address - Country:US
Practice Address - Phone:248-682-2050
Practice Address - Fax:248-618-3742
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI13752122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12 3053026Medicaid