Provider Demographics
NPI:1316299365
Name:NORTHERN PERIODONTICS & IMPLANT DENTISTRY, P.C.
Entity type:Organization
Organization Name:NORTHERN PERIODONTICS & IMPLANT DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VAUGHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCGRAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:231-347-2518
Mailing Address - Street 1:2115 M 119
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8914
Mailing Address - Country:US
Mailing Address - Phone:231-347-2518
Mailing Address - Fax:231-347-8530
Practice Address - Street 1:2115 M 119
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8914
Practice Address - Country:US
Practice Address - Phone:231-347-2518
Practice Address - Fax:231-347-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010140671223P0300X
MI29010101591223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1750493896Medicaid
MI1255443321Medicaid