Provider Demographics
NPI:1053731695
Name:GARY A. SCHLUCKEBIER, DDS, PLLC
Entity type:Organization
Organization Name:GARY A. SCHLUCKEBIER, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHLUCKEBIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-875-4721
Mailing Address - Street 1:921 N PINE RIVER ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847-1119
Mailing Address - Country:US
Mailing Address - Phone:989-875-4721
Mailing Address - Fax:989-875-6018
Practice Address - Street 1:921 N PINE RIVER ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-1119
Practice Address - Country:US
Practice Address - Phone:989-875-4721
Practice Address - Fax:989-875-6018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0168371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty