Provider Demographics
NPI:1366584880
Name:PAINE, GEOFFREY ROLAND (DDS)
Entity type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:ROLAND
Last Name:PAINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 WATER ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-1544
Mailing Address - Country:US
Mailing Address - Phone:231-723-7957
Mailing Address - Fax:231-723-3230
Practice Address - Street 1:504 WATER ST
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-1544
Practice Address - Country:US
Practice Address - Phone:231-723-7957
Practice Address - Fax:231-723-3230
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI139271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice