Basic Information
| Provider Information | |||||||||
| NPI: | 1578786034 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LENAWEE DENTAL CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | ADRIAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492212723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172660651 | ||||||||
| FaxNumber: | 5172668476 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | ADRIAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492212723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172660651 | ||||||||
| FaxNumber: | 5172668476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/23/2007 | ||||||||
| NPIReactivationDate: | 04/30/2007 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LARK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT BOARD OF DIRECTORS | ||||||||
| AuthorizedOfficialTelephone: | 5172639022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 18869 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.