Provider Demographics
NPI:1558410902
Name:LA FAYETTE, GREGORY DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DAVID
Last Name:LA FAYETTE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N LAKE ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-1234
Mailing Address - Country:US
Mailing Address - Phone:906-341-6132
Mailing Address - Fax:906-341-3054
Practice Address - Street 1:115 N LAKE ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-1234
Practice Address - Country:US
Practice Address - Phone:906-341-6132
Practice Address - Fax:906-341-3054
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010162941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2952112Medicaid
MID802465OtherBLUE CROSS BLUE SHIELD