Provider Demographics
NPI:1952428310
Name:GRAND LAKE FAMILY DENTISTRY, LTD.
Entity Type:Organization
Organization Name:GRAND LAKE FAMILY DENTISTRY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-586-1615
Mailing Address - Street 1:800 E WAYNE ST
Mailing Address - Street 2:PO BOX 316
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-1359
Mailing Address - Country:US
Mailing Address - Phone:419-586-1615
Mailing Address - Fax:419-586-1616
Practice Address - Street 1:800 E WAYNE ST
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-1359
Practice Address - Country:US
Practice Address - Phone:419-586-1615
Practice Address - Fax:419-586-1616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.020826122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9182631OtherDENTAQUEST
OH2057965Medicaid
06131OtherPARAMOUNT