Provider Demographics
NPI:1720413636
Name:616 DENTAL STUDIO PLLC
Entity Type:Organization
Organization Name:616 DENTAL STUDIO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCOS
Authorized Official - Middle Name:
Authorized Official - Last Name:CID
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:616-214-7865
Mailing Address - Street 1:171 MONROE AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2634
Mailing Address - Country:US
Mailing Address - Phone:616-214-7865
Mailing Address - Fax:
Practice Address - Street 1:171 MONROE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2634
Practice Address - Country:US
Practice Address - Phone:616-214-7865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020846122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty