Provider Demographics
NPI:1407388416
Name:GROSSE POINTE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:GROSSE POINTE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PANAGOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-882-9729
Mailing Address - Street 1:18501 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3224
Mailing Address - Country:US
Mailing Address - Phone:313-882-9729
Mailing Address - Fax:
Practice Address - Street 1:18501 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3224
Practice Address - Country:US
Practice Address - Phone:313-882-9729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI13571122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty