Provider Demographics
NPI:1396756615
Name:BLUE WATER FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:BLUE WATER FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-385-2273
Mailing Address - Street 1:4044 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059
Mailing Address - Country:US
Mailing Address - Phone:810-385-2273
Mailing Address - Fax:810-385-6285
Practice Address - Street 1:4044 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059
Practice Address - Country:US
Practice Address - Phone:810-385-2273
Practice Address - Fax:810-385-6285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI16113122300000X
MI15282122300000X
MI16735122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty