Provider Demographics
NPI:1720323173
Name:GREAT LAKES FAMILY DENTAL GROUP - GRAND BLANC
Entity Type:Organization
Organization Name:GREAT LAKES FAMILY DENTAL GROUP - GRAND BLANC
Other - Org Name:GREAT LAKES FAMILY DENTAL GROUP - FLINT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-732-0200
Mailing Address - Street 1:8542 HOLLY ROAD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439
Mailing Address - Country:US
Mailing Address - Phone:810-603-7887
Mailing Address - Fax:810-720-1306
Practice Address - Street 1:8542 HOLLY ROAD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439
Practice Address - Country:US
Practice Address - Phone:810-603-7887
Practice Address - Fax:810-720-1306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
MI29010122571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty