Individual
MITCH TY CARPENTER-THOMPSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
213 S CANAL ST, LAKE CITY, MI 49651-8865
(231) 839-2630
Mailing address
PO BOX 719, LAKE CITY, MI 49651-0719
(231) 839-2630
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
014317
MI
1223G0001X
General Practice Dentistry
Primary
600446
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
600446
LICENSE
MI
Enumeration date
07/06/2020
Last updated
10/07/2021
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