Provider Demographics
NPI:1518269877
Name:GRAND RIVER ORTHODONTICS, PC
Entity Type:Organization
Organization Name:GRAND RIVER ORTHODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:GIETZEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-879-0200
Mailing Address - Street 1:1335 W MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-1555
Mailing Address - Country:US
Mailing Address - Phone:616-897-0200
Mailing Address - Fax:
Practice Address - Street 1:1335 W MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1555
Practice Address - Country:US
Practice Address - Phone:616-897-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010188021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty