Provider Demographics
NPI:1659906204
Name:GRAND RAPIDS DENTAL CARE LLC
Entity Type:Organization
Organization Name:GRAND RAPIDS DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-326-3438
Mailing Address - Street 1:220 SE 21ST ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4268
Mailing Address - Country:US
Mailing Address - Phone:218-326-3438
Mailing Address - Fax:
Practice Address - Street 1:220 SE 21ST ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4268
Practice Address - Country:US
Practice Address - Phone:218-326-3438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
T65577OtherUPIN