Provider Demographics
NPI:1730276411
Name:TOOTH TIME
Entity type:Organization
Organization Name:TOOTH TIME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOLLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:269-731-4581
Mailing Address - Street 1:7057 STONEY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:MI
Mailing Address - Zip Code:49012-8883
Mailing Address - Country:US
Mailing Address - Phone:269-731-4581
Mailing Address - Fax:
Practice Address - Street 1:7057 STONEY CREEK DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:MI
Practice Address - Zip Code:49012-8883
Practice Address - Country:US
Practice Address - Phone:269-731-4581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010172741223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4915898Medicaid