Provider Demographics
NPI:1629664511
Name:GRASSE RIVER FAMILY DENTAL
Entity Type:Organization
Organization Name:GRASSE RIVER FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELI
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOLLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-386-2960
Mailing Address - Street 1:1956 OLD DEKALB RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3134
Mailing Address - Country:US
Mailing Address - Phone:315-386-2960
Mailing Address - Fax:315-386-2960
Practice Address - Street 1:1956 OLD DEKALB RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3134
Practice Address - Country:US
Practice Address - Phone:315-386-2960
Practice Address - Fax:315-386-2960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental