Provider Demographics
NPI:1023627163
Name:GRAND RIDGE FAMILY DENTISTRY
Entity type:Organization
Organization Name:GRAND RIDGE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-447-7800
Mailing Address - Street 1:3350 GRAND RIDGE DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7071
Mailing Address - Country:US
Mailing Address - Phone:616-447-7800
Mailing Address - Fax:616-447-9611
Practice Address - Street 1:3350 GRAND RIDGE DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7071
Practice Address - Country:US
Practice Address - Phone:616-447-7800
Practice Address - Fax:616-447-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental