Provider Demographics
NPI:1366044158
Name:GRAND LAKE FAMILY DENTISTRY TRAVIS D LUTZ DDS- ROCKFORD LTD
Entity Type:Organization
Organization Name:GRAND LAKE FAMILY DENTISTRY TRAVIS D LUTZ DDS- ROCKFORD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-305-9983
Mailing Address - Street 1:160 E. WALNUT ST.
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45882
Mailing Address - Country:US
Mailing Address - Phone:419-363-3537
Mailing Address - Fax:
Practice Address - Street 1:160 E. WALNUT ST.
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:OH
Practice Address - Zip Code:45882
Practice Address - Country:US
Practice Address - Phone:419-363-3537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty