MEDICARE: GD MI RIVERVIEW 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1629724679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GD MI RIVERVIEW PLLC

Provider Business Mailing Address
First Line	:	17128 FORT ST
Second Line	:
City	:	RIVERVIEW
State	:	MI
Zip	:	48193-6619
Country	:	US
Telephone Number	:	734-281-3200
Fax Number	:

Provider Business Practice Location Address
First Line	:	17128 FORT ST
Second Line	:
City	:	RIVERVIEW
State	:	MI
Zip	:	48193-6619
Country	:	US
Telephone Number	:	734-281-3200
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIAING
Name	:	CHAD HENDRICKS
Credential	:
Telephone Number	:	612-859-0444

Provider Enumeration Date	:	02/28/2022
Last Update Date	:	02/28/2022

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Directions to “GD MI RIVERVIEW PLLC ” Practice Location

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