Provider Demographics
NPI:1508126517
Name:GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS
Other - Org Name:GTB DENTAL CLINC
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-534-7477
Mailing Address - Street 1:2300 N STALLMAN ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PESHAWBESTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:49682
Mailing Address - Country:US
Mailing Address - Phone:231-534-7211
Mailing Address - Fax:231-534-7460
Practice Address - Street 1:2300 N STALLMAN ROAD
Practice Address - Street 2:
Practice Address - City:PESHAWBESTOWN
Practice Address - State:MI
Practice Address - Zip Code:49682
Practice Address - Country:US
Practice Address - Phone:231-534-7211
Practice Address - Fax:231-534-7460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QD0000X261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental