Provider Demographics
NPI:1720173529
Name:ZIETZ, LONNY E (DDS, MS)
Entity Type:Individual
Prefix:
First Name:LONNY
Middle Name:E
Last Name:ZIETZ
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 LAKE MICHIGAN DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4785
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2140 LAKE MICHIGAN DR NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4785
Practice Address - Country:US
Practice Address - Phone:616-791-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010096651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D111530OtherBCBSM
MI096650OtherBCBSD
MICC0861 - 190005423Medicare ID - Type UnspecifiedRAILROAD-MEDICARE
MI096650OtherBCBSD