Provider Demographics
NPI:1295145092
Name:GRAND DENTISTRY
Entity type:Organization
Organization Name:GRAND DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEEPAN
Authorized Official - Middle Name:PRAVIN
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DND
Authorized Official - Phone:616-443-5097
Mailing Address - Street 1:116 W GRAND AVE
Mailing Address - Street 2:#1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5207
Mailing Address - Country:US
Mailing Address - Phone:312-955-9020
Mailing Address - Fax:
Practice Address - Street 1:116 W GRAND AVE
Practice Address - Street 2:#1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-5207
Practice Address - Country:US
Practice Address - Phone:312-955-9020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190285101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty