Provider Demographics
NPI:1366764946
Name:MICHAEL GLASS FAMILY AND COSMETIC DENTRY
Entity type:Organization
Organization Name:MICHAEL GLASS FAMILY AND COSMETIC DENTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:LILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLYTHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-963-9670
Mailing Address - Street 1:131 E COLUMBIA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-3788
Mailing Address - Country:US
Mailing Address - Phone:269-963-9670
Mailing Address - Fax:269-963-9672
Practice Address - Street 1:131 E COLUMBIA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-3788
Practice Address - Country:US
Practice Address - Phone:269-963-9670
Practice Address - Fax:269-963-9672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4709263Medicaid