Provider Demographics
NPI:1518360304
Name:GRAND RIVER ENDODONTICS PC
Entity Type:Organization
Organization Name:GRAND RIVER ENDODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:LENNAN
Authorized Official - Last Name:MASTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:616-249-3500
Mailing Address - Street 1:4211 PARKWAY PLACE DR SW
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2695
Mailing Address - Country:US
Mailing Address - Phone:616-249-3500
Mailing Address - Fax:616-249-3502
Practice Address - Street 1:4211 PARKWAY PLACE DR SW
Practice Address - Street 2:SUITE 104
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2695
Practice Address - Country:US
Practice Address - Phone:616-249-3500
Practice Address - Fax:616-249-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-07
Last Update Date:2017-09-30
Deactivation Date:2014-10-21
Deactivation Code:
Reactivation Date:2017-09-30
Provider Licenses
StateLicense IDTaxonomies
MI29010194571223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty