Provider Demographics
NPI:1881843878
Name:GRANDVILLE DENTAL HEALTH CENTER PC
Entity type:Organization
Organization Name:GRANDVILLE DENTAL HEALTH CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-531-0360
Mailing Address - Street 1:4050 DEL MAR DR SW
Mailing Address - Street 2:SUITE B
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-8870
Mailing Address - Country:US
Mailing Address - Phone:616-531-0360
Mailing Address - Fax:616-531-2810
Practice Address - Street 1:4050 DEL MAR DR SW
Practice Address - Street 2:SUITE B
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-8870
Practice Address - Country:US
Practice Address - Phone:616-531-0360
Practice Address - Fax:616-531-2810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-15
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019378122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4487030Medicaid