Provider Demographics
NPI:1639807993
Name:MATTAWAN DENTAL, PLC, DBA TEXAS CORNERS DENTAL
Entity Type:Organization
Organization Name:MATTAWAN DENTAL, PLC, DBA TEXAS CORNERS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:KRISTINA
Authorized Official - Last Name:GRISWOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:269-352-0980
Mailing Address - Street 1:6780 W Q AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3961
Mailing Address - Country:US
Mailing Address - Phone:269-372-2400
Mailing Address - Fax:
Practice Address - Street 1:6780 W Q AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-3961
Practice Address - Country:US
Practice Address - Phone:269-372-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental