Provider Demographics
NPI:1235497595
Name:BRIGHT SIDE DENTAL-ST. CLAIR SHORES PLLC
Entity Type:Organization
Organization Name:BRIGHT SIDE DENTAL-ST. CLAIR SHORES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRYTZELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-439-2940
Mailing Address - Street 1:31245 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-1401
Mailing Address - Country:US
Mailing Address - Phone:586-439-2940
Mailing Address - Fax:
Practice Address - Street 1:31245 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-1401
Practice Address - Country:US
Practice Address - Phone:586-439-2940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010189701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty