Provider Demographics
NPI:1700269735
Name:GANTZ DDS PLLC
Entity Type:Organization
Organization Name:GANTZ DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:K
Authorized Official - Last Name:GANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-353-4010
Mailing Address - Street 1:25865 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1817
Mailing Address - Country:US
Mailing Address - Phone:248-353-4010
Mailing Address - Fax:248-353-0829
Practice Address - Street 1:25865 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1817
Practice Address - Country:US
Practice Address - Phone:248-353-4010
Practice Address - Fax:248-353-0829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901013299122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty