Provider Demographics
NPI:1457644049
Name:GRAND DENTAL CENTER
Entity Type:Organization
Organization Name:GRAND DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-326-0339
Mailing Address - Street 1:1604 GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-8648
Mailing Address - Country:US
Mailing Address - Phone:218-326-0339
Mailing Address - Fax:218-999-5443
Practice Address - Street 1:1604 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-8648
Practice Address - Country:US
Practice Address - Phone:218-326-0339
Practice Address - Fax:218-999-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11285122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty