Provider Demographics
NPI:1073265542
Name:GREAT LAKES DENTISTRY CHESTERFIELD
Entity Type:Organization
Organization Name:GREAT LAKES DENTISTRY CHESTERFIELD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DE VYVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-320-8939
Mailing Address - Street 1:73501 WINDMILL DR
Mailing Address - Street 2:
Mailing Address - City:BRUCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48065-3159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34301 23 MILE RD STE 140A
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-4432
Practice Address - Country:US
Practice Address - Phone:586-725-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental