Organization
MICHIGAN PERIODONTICS GROUP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SHAWN MICHAEL ETHERTON (REGIONAL MANAGER)
(616) 780-6879
Entity
Organization
Contact information
Practice address
350 N MAIN ST STE 110, CHELSEA, MI 48118-1486
(734) 719-2700
Mailing address
350 NORTH MAIN STREET SUITE 110, CHELSEA, MI 48118
(734) 719-2700
Taxonomy
Speciality
Code
Description
License number
State
1223P0300X
Periodontics
Primary
2901021083
MI
Other
Enumeration date
02/20/2017
Last updated
02/20/2017
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