MEDICARE: AFFINITY DENTAL CARE PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1629497631	OTHER	GA	NPPES

General Provider Information

NPI Number	:	1194421909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFINITY DENTAL CARE PLC

Provider Business Mailing Address
First Line	:	PO BOX 141547
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49514-1547
Country	:	US
Telephone Number	:	404-207-2605
Fax Number	:

Provider Business Practice Location Address
First Line	:	2807 LAKE MICHIGAN DR NW STE 3
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-5831
Country	:	US
Telephone Number	:	678-462-0499
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MANUEL R ALE
Credential	:	MBA
Telephone Number	:	404-207-2605

Provider Enumeration Date	:	02/02/2023
Last Update Date	:	02/02/2023

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Directions to “AFFINITY DENTAL CARE PLC ” Practice Location

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