Provider Demographics
NPI:1336782135
Name:GREAT LAKES BAY ORTHODONTICS, PLC
Entity Type:Organization
Organization Name:GREAT LAKES BAY ORTHODONTICS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:GRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:989-600-8037
Mailing Address - Street 1:200 NORTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-7344
Mailing Address - Country:US
Mailing Address - Phone:989-631-1334
Mailing Address - Fax:
Practice Address - Street 1:200 NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-7344
Practice Address - Country:US
Practice Address - Phone:989-631-1334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty