Provider Demographics
NPI:1588767123
Name:MICHIGAN DENTAL PROFESSIONALS, PLLC
Entity type:Organization
Organization Name:MICHIGAN DENTAL PROFESSIONALS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:MCLAREN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:989-754-8155
Mailing Address - Street 1:1227 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4729
Mailing Address - Country:US
Mailing Address - Phone:989-754-8155
Mailing Address - Fax:989-754-8156
Practice Address - Street 1:1227 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4729
Practice Address - Country:US
Practice Address - Phone:989-754-8155
Practice Address - Fax:989-754-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010180861223G0001X
MI29010180851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty