Provider Demographics
NPI:1255404992
Name:GEORGETOWN FAMILY & COSMETIC DENTISTRY PLC
Entity type:Organization
Organization Name:GEORGETOWN FAMILY & COSMETIC DENTISTRY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-457-4600
Mailing Address - Street 1:7678 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428
Mailing Address - Country:US
Mailing Address - Phone:616-457-4600
Mailing Address - Fax:616-457-6021
Practice Address - Street 1:7678 COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428
Practice Address - Country:US
Practice Address - Phone:616-457-4600
Practice Address - Fax:616-457-4600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
J801114OtherBCBS ID #