Provider Demographics
NPI:1053992057
Name:NORTHERN FAMILY DENTAL PLC
Entity type:Organization
Organization Name:NORTHERN FAMILY DENTAL PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:KWAPISZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-547-4148
Mailing Address - Street 1:106 E GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1721
Mailing Address - Country:US
Mailing Address - Phone:231-547-4148
Mailing Address - Fax:231-547-5670
Practice Address - Street 1:106 E GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1721
Practice Address - Country:US
Practice Address - Phone:231-547-4148
Practice Address - Fax:231-547-5670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-20
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIK120098730197Medicaid