Provider Demographics
NPI:1871865832
Name:GREAT LAKES DENTISTRY SHELBY
Entity Type:Organization
Organization Name:GREAT LAKES DENTISTRY SHELBY
Other - Org Name:GREAT LAKES DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DE VYVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-320-8939
Mailing Address - Street 1:73501 WINDMILL DR
Mailing Address - Street 2:
Mailing Address - City:BRUCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48065-3159
Mailing Address - Country:US
Mailing Address - Phone:734-320-8939
Mailing Address - Fax:
Practice Address - Street 1:53620 VAN DYKE AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48316-1831
Practice Address - Country:US
Practice Address - Phone:586-677-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019702122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty