1366873937 NPI number — GREAT LAKES FAMILY DENTAL GROUP-LANSING, P.C.

Table of content: (NPI 1366873937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366873937 NPI number — GREAT LAKES FAMILY DENTAL GROUP-LANSING, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES FAMILY DENTAL GROUP-LANSING, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366873937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3515 COOLIDGE RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
EAST LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48823-8014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-230-3245
Provider Business Mailing Address Fax Number:
810-230-3229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3515 COOLIDGE ROAD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-332-2422
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
C.
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
810-732-0200

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  12257 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PTAN7290590001 . This is a "PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".