Provider Demographics
NPI:1437892700
Name:MIDDEL, MARIAH GRACE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIAH
Middle Name:GRACE
Last Name:MIDDEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 WILSON AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-8709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4625 WILSON AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-8709
Practice Address - Country:US
Practice Address - Phone:616-530-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601380122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist