MEDICARE: GRAND VALLEY DENTAL CARE, P.C.

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	1223G0001X	General Practice Dentistry	08282	MI

General Provider Information

NPI Number	:	1568599660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND VALLEY DENTAL CARE, P.C.

Provider Business Mailing Address
First Line	:	2020 DIVISION AVE S
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-3029
Country	:	US
Telephone Number	:	616-245-2767
Fax Number	:	616-245-0498

Provider Business Practice Location Address
First Line	:	2020 DIVISION AVE S
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-3029
Country	:	US
Telephone Number	:	616-245-2767
Fax Number	:	616-245-0498

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. CARMY G MICHAEL
Credential	:	D.D.S.
Telephone Number	:	616-245-2767

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	08/22/2020

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