Provider Demographics
NPI:1508031808
Name:GRANDVILLE ENDODONTICS
Entity Type:Organization
Organization Name:GRANDVILLE ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LICARI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-531-0780
Mailing Address - Street 1:3100 IVANREST AVE SW
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2930
Mailing Address - Country:US
Mailing Address - Phone:616-531-0780
Mailing Address - Fax:616-531-4677
Practice Address - Street 1:3100 IVANREST AVE SW
Practice Address - Street 2:SUITE 104
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2930
Practice Address - Country:US
Practice Address - Phone:616-531-0780
Practice Address - Fax:616-531-4677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty