Blue Water Dental Group Marysville PC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

2901008847 Issued in MI

Legal business name

BLUE WATER DENTAL GROUP MARYSVILLE PC

Practice address

1616 Gratiot Blvd
Maryville, MI 48040-1181

Phone

(810) 364-7601

Fax

(810) 364-9010

NPI assigned

Aug 29, 2006

Organization subpart

No

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

Authorized official

Name

Dr. William Lee Kile, DDS FICCMO

Title

President

Phone

(810) 364-7601

Specialties & licenses 1

Addresses

Locations

Practitioners 1

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

• Shane Michael Langolf, DMD

  • General Practice Dentistry
  • Marysville, MI
  • NPI 1194716670
  NPD (past)

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

{
    "created_epoch": "1156809600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1508975319",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1616 GRATIOT BLVD",
            "city": "MARYVILLE",
            "state": "MI",
            "postal_code": "480401181",
            "telephone_number": "810-364-7601",
            "fax_number": "810-364-9010"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1616 GRATIOT BLVD",
            "city": "MARYVILLE",
            "state": "MI",
            "postal_code": "480401181",
            "telephone_number": "810-364-7601",
            "fax_number": "810-364-9010"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE WATER DENTAL GROUP MARYSVILLE PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-29",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "KILE",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "810-364-7601",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS  FICCMO"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "2901008847",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.