Provider Demographics
NPI:1497077630
Name:GREAT LAKES FAMILY DENTAL GROUP-LIVONIA, P.C.
Entity Type:Organization
Organization Name:GREAT LAKES FAMILY DENTAL GROUP-LIVONIA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:C
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-732-0200
Mailing Address - Street 1:G3222 BEECHER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3614
Mailing Address - Country:US
Mailing Address - Phone:810-230-3245
Mailing Address - Fax:810-230-3229
Practice Address - Street 1:16160 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-3338
Practice Address - Country:US
Practice Address - Phone:734-261-9696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI122300000X1223G0001X
MI1223S0112X1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty