Provider Demographics
NPI:1144457672
Name:NORTHERN QUALITY DENTAL
Entity type:Organization
Organization Name:NORTHERN QUALITY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JARVIS
Authorized Official - Last Name:SEYMOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-775-6531
Mailing Address - Street 1:504 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-1809
Mailing Address - Country:US
Mailing Address - Phone:231-775-6531
Mailing Address - Fax:231-775-6431
Practice Address - Street 1:504 HAYNES ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-1809
Practice Address - Country:US
Practice Address - Phone:231-775-6531
Practice Address - Fax:231-775-6431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010-194031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883238OtherUNITED CONCORDIA
MI4919510Medicaid
MID194030OtherBCBS
MI4918174Medicaid
MI4919485Medicaid
MI1883242OtherUNITED CONCORDIA
MI4918183Medicaid
MI4919500Medicaid
MI4919494Medicaid
MID194040OtherBCBS