MEDICARE: GRASS LAKE DENTAL CENTER PLLC

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

General Provider Information

NPI Number	:	1386388114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRASS LAKE DENTAL CENTER PLLC

Provider Business Mailing Address
First Line	:	2143 ORCHARDVIEW
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48108-2766
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11745 E MICHIGAN AVE
Second Line	:
City	:	GRASS LAKE
State	:	MI
Zip	:	49240-9219
Country	:	US
Telephone Number	:	517-522-5018
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. LUCIANA GABRIELA CASTRO
Credential	:	DDS
Telephone Number	:	734-355-0779

Provider Enumeration Date	:	04/27/2022
Last Update Date	:	04/27/2022

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