Provider Demographics
NPI:1851078422
Name:PELLEGROM, COLIN WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:WILLIAM
Last Name:PELLEGROM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 ROBBINS RD
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2695
Mailing Address - Country:US
Mailing Address - Phone:616-842-2850
Mailing Address - Fax:
Practice Address - Street 1:575 ROBBINS RD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2695
Practice Address - Country:US
Practice Address - Phone:616-842-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601824122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist