| Full Name | |
|---|---|
| Speciality | Dentist |
| Location | 110 S Dryden St, Hart, Michigan |
| Authorized Official Name and Position | Grant Kurtis Gillish (DENTIST/OWNER) |
| Authorized Official Contact | 2318734025 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
110 S Dryden St Hart MI 49420-1105 Ph: (231) 873-4025 | 110 S Dryden St Hart MI 49420-1105 Ph: (231) 873-4025 |
| NPI Number | 1902423239 |
|---|---|
| Provider Enumeration Date | 07/02/2020 |
| Last Update Date | 07/23/2020 |
| Medicare PECOS PAC ID | 4789095829 |
|---|---|
| Medicare Enrollment ID | O20201123000422 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1902423239 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | (* (Not Available)) | Primary |
| Provider Name | Grant K Gillish |
|---|---|
| Provider Type | Practitioner - Dentist |
| Provider Identifiers | NPI Number: 1659681591 PECOS PAC ID: 5799088720 Enrollment ID: I20201222000947 |