Provider Demographics
NPI:1053525899
Name:FAMILY DENTAL SERVICES PC
Entity type:Organization
Organization Name:FAMILY DENTAL SERVICES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-224-2379
Mailing Address - Street 1:911 E STATE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-1684
Mailing Address - Country:US
Mailing Address - Phone:989-224-2379
Mailing Address - Fax:
Practice Address - Street 1:911 E STATE ST
Practice Address - Street 2:SUITE C
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-1684
Practice Address - Country:US
Practice Address - Phone:989-224-2379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI134321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty