NPIMap

Organization Active NPI

Pediatric Dental Specilaist, P.C

  • Pediatric Dentistry
  • Port Huron, MI
National Provider Identifier
1255063244
Registry record updated Jul 26, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
Legal business name
PEDIATRIC DENTAL SPECILAIST, P.C
Practice address
1026 Superior St
Port Huron, MI 48060-3748
Phone
(810) 987-5040
Fax
(810) 987-9499
NPI assigned
Jun 28, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 26, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kacey A Woodward
Title
Receptionist
Phone
(810) 987-5040

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0221X Primary

Addresses

Primary practice location

1026 Superior St
Port Huron, MI 48060-3748

Mailing address

1026 Superior St
Port Huron, MI 48060-3748
Phone (810) 987-5040

Other identifiers 1

IdentifierTypeStateIssuer
4032586MedicaidMI

Electronic endpoints 1

TypeEndpointUseAffiliation
Other URL Mail Direct

National Provider Directory

National Provider Directory

Locations

1026 Superior St
Port Huron, MI 48060
Phone (810) 987-5040

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1656374400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658793600000",
    "number": "1255063244",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1026 SUPERIOR ST",
            "city": "PORT HURON",
            "state": "MI",
            "postal_code": "480603748",
            "telephone_number": "810-987-5040",
            "fax_number": "810-987-9499"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1026 SUPERIOR ST",
            "city": "PORT HURON",
            "state": "MI",
            "postal_code": "480603748",
            "telephone_number": "810-987-5040",
            "fax_number": "810-987-9499"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC DENTAL SPECILAIST, P.C",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-06-28",
        "last_updated": "2022-07-26",
        "certification_date": "2022-07-26",
        "status": "A",
        "authorized_official_last_name": "WOODWARD",
        "authorized_official_first_name": "KACEY",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "RECEPTIONIST",
        "authorized_official_telephone_number": "810-987-5040"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4032586",
            "state": "MI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "Mail",
            "affiliation": "N",
            "endpointDescription": "Mail",
            "use": "DIRECT",
            "useDescription": "Direct",
            "useOtherDescription": "Mail",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Mail",
            "address_1": "1026 Superior St",
            "city": "Port Huron",
            "state": "MI",
            "country_code": "US",
            "postal_code": "480603748",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Port Huron, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 26, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.