Provider Demographics
NPI:1790215028
Name:CASEVILLE FAMILY DENTISTRY, PC
Entity type:Organization
Organization Name:CASEVILLE FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:REDWANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-856-4096
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:CASEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48725-0279
Mailing Address - Country:US
Mailing Address - Phone:989-856-4096
Mailing Address - Fax:989-856-4025
Practice Address - Street 1:6982 MAIN ST
Practice Address - Street 2:
Practice Address - City:CASEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48725-5110
Practice Address - Country:US
Practice Address - Phone:989-856-4096
Practice Address - Fax:989-856-4025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI156271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI15627OtherSTATE DENTAL LICENSE