Provider Demographics
NPI:1366976854
Name:NORTHWOOD COSMETIC DENTAL GROUP, PC
Entity type:Organization
Organization Name:NORTHWOOD COSMETIC DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:KLYM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-947-7202
Mailing Address - Street 1:10748 E TRAVERSE HWY
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5550
Mailing Address - Country:US
Mailing Address - Phone:231-947-7202
Mailing Address - Fax:231-933-3401
Practice Address - Street 1:10748 E TRAVERSE HWY
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-5550
Practice Address - Country:US
Practice Address - Phone:231-947-7202
Practice Address - Fax:231-933-3401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016991122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty