# STATE STREET FAMILY DENTAL

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1669604484
- **Authorized official:** JENNIFER NICOLE OSBORNE (OFFICE MANAGER)
- **Authorized official phone:** (989) 227-1858

## Contact information

- **Practice address:** 100 S SCOTT RD, SAINT JOHNS, MI 48879-9038
- **Practice address phone:** (989) 227-1858
- **Practice address fax:** (989) 227-2268
- **Mailing address:** 100 S SCOTT RD, SAINT JOHNS, MI 48879-9038
- **Mailing address phone:** (989) 227-1858
- **Mailing address fax:** (989) 227-2268

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 012271 | MI | — |
| 122300000X | Dentist | 13188 | MI | Yes |
| 122300000X | Dentist | 2901018410 | MI | — |
| 122300000X | Dentist | 2901019279 | MI | — |
| 122300000X | Dentist | 901013605 | MI | — |

## Other

- **Enumeration date:** 08/12/2009
- **Last updated:** 08/12/2009