Organization
NORTHERN MICHIGAN PEDIATRIC DENTISTRY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JAMES M VAN WINGEN DDS (DENTIST)
(231) 947-4566
Entity
Organization
Contact information
Practice address
4944 SKYVIEW CT, TRAVERSE CITY, MI 49684-7173
(231) 947-4566
Mailing address
4944 SKYVIEW CT, TRAVERSE CITY, MI 49684-7173
(231) 947-4566
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
2901017484
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4457700
MEDICAID
MI
01
—
D158620
BLUE CROSS BLUE SHIELD MI
MI
Enumeration date
01/18/2007
Last updated
08/22/2020
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