Basic Information
| Provider Information | |||||||||
| NPI: | 1508126517 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GTB DENTAL CLINC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 N STALLMAN ROAD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PESHAWBESTOWN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315347211 | ||||||||
| FaxNumber: | 2315347460 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 N STALLMAN ROAD | ||||||||
| Address2: | |||||||||
| City: | PESHAWBESTOWN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315347211 | ||||||||
| FaxNumber: | 2315347460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2012 | ||||||||
| LastUpdateDate: | 12/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | CHAMBERS | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2315347477 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 261QD0000X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.