NPIMap

Organization Active NPI

Bay Mills Indian Community

Doing business as Mitigoons Dental

  • Federally Qualified Health Center (FQHC)
  • Sault Sainte Marie, MI
National Provider Identifier
1366409237
Registry record updated Jun 20, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BAY MILLS INDIAN COMMUNITY
Doing business as
Mitigoons Dental
Practice address
204 E Portage Ave
Sault Sainte Marie, MI 49783-2054
Phone
(906) 248-5527
Fax
(906) 248-5765
NPI assigned
Apr 26, 2006
Last updated
Jun 20, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 20, 2023

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

Authorized official

Name
Audrey Breakie
Title
HHS Dirctor
Phone
(906) 248-8315

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

204 E Portage Ave
Sault Sainte Marie, MI 49783-2054

Mailing address

12455 W Lakeshore Dr
Brimley, MI 49715-9327
Phone (906) 248-5527

Other names 1

  • Mitigoons Dental Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240104002493 MI Part A Provider - Federally Qualified Health Center (FQHC) 8729079918 Practice locations: Sault Sainte Marie, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1366409237. Details of each certification follow.

Federally qualified health center certification: CCN C71010

Legal name
BAY MILLS INDIAN COMMUNITY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 27, 2023
Last certification
Dec 27, 2023
Ownership / control type
For profit – corporation
Organization structure
GovernmentNon-profit
Incorporated
Jan 1, 2001 in MI
Enrollment address
204 E Portage Ave
Sault Sainte Marie, MI 49783-2054

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Bay Mills Indian Community10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Lucy Dewildt Individual Corporate DirectorAssistant HHS Director Sep 1, 2022 50%
W-2 Managing EmployeeHealth & Human Services Director Jul 8, 2024 100%
Abby L Kaunisto Individual W-2 Managing EmployeeClinic Coordinator Jul 5, 2015
Bay Mills Indian Community Organization, Brimley, MI 5% Or Greater Direct Ownership Interest Dec 13, 2023 100%

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Bay Mills Indian CommunityBrimley, MI, CCN 231839 Federally qualified health center Operational/Managerial Control Jan 1, 1993

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1146009600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1687219200000",
    "number": "1366409237",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12455 W LAKESHORE DR",
            "city": "BRIMLEY",
            "state": "MI",
            "postal_code": "497159327",
            "telephone_number": "906-248-5527",
            "fax_number": "906-248-5765"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "204 E PORTAGE AVE",
            "city": "SAULT SAINTE MARIE",
            "state": "MI",
            "postal_code": "497832054",
            "telephone_number": "906-248-5527",
            "fax_number": "906-248-5765"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BAY MILLS INDIAN COMMUNITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-26",
        "last_updated": "2023-06-20",
        "certification_date": "2023-06-20",
        "status": "A",
        "authorized_official_last_name": "BREAKIE",
        "authorized_official_first_name": "AUDREY",
        "authorized_official_title_or_position": "HHS DIRCTOR",
        "authorized_official_telephone_number": "906-248-8315"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mitigoons Dental",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sault Sainte Marie, MI

Sources for this page

Verify at the official NPI Registry.