Provider Demographics
NPI:1902019623
Name:GRAPEVINE DENTURE SERVICE
Entity Type:Organization
Organization Name:GRAPEVINE DENTURE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-943-8409
Mailing Address - Street 1:865 US HIGHWAY 31 S
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8716
Mailing Address - Country:US
Mailing Address - Phone:231-943-8409
Mailing Address - Fax:
Practice Address - Street 1:865 US HIGHWAY 31 S
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8716
Practice Address - Country:US
Practice Address - Phone:231-943-8409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI081281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty