Provider Demographics
NPI:1659802395
Name:GREAT LAKES ENDODONTICS
Entity Type:Organization
Organization Name:GREAT LAKES ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:YEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:269-349-2189
Mailing Address - Street 1:950 TRADE CENTRE WAY
Mailing Address - Street 2:STE 225
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-0487
Mailing Address - Country:US
Mailing Address - Phone:269-349-2189
Mailing Address - Fax:
Practice Address - Street 1:950 TRADE CENTRE WAY
Practice Address - Street 2:STE 225
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-0487
Practice Address - Country:US
Practice Address - Phone:269-349-2189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010199631223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty