Provider Demographics
NPI:1841345014
Name:GULL LAKE DENTAL CARE PC
Entity type:Organization
Organization Name:GULL LAKE DENTAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-629-9817
Mailing Address - Street 1:9271 E D AVE
Mailing Address - Street 2:PO BOX 9
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-9497
Mailing Address - Country:US
Mailing Address - Phone:269-629-9817
Mailing Address - Fax:269-629-0195
Practice Address - Street 1:9271 E D AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083-9497
Practice Address - Country:US
Practice Address - Phone:269-629-9817
Practice Address - Fax:269-629-0195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI16980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty