Provider Demographics
NPI:1477894442
Name:LEGACY DENTAL GROUP, PC
Entity Type:Organization
Organization Name:LEGACY DENTAL GROUP, PC
Other - Org Name:LEGACY DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRABIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-644-3131
Mailing Address - Street 1:950 S OLD WOODWARD AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6719
Mailing Address - Country:US
Mailing Address - Phone:248-644-9120
Mailing Address - Fax:248-282-5060
Practice Address - Street 1:950 S OLD WOODWARD AVE STE 200
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6719
Practice Address - Country:US
Practice Address - Phone:248-644-9120
Practice Address - Fax:248-282-5060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-15
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI012169261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental