Healthcare Provider Details

I. General information

NPI: 1174141741
Provider Name (Legal Business Name): GOOD TO GROW DENTAL CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21781 OMEGA CT
GOSHEN IN
46528-7809
US

IV. Provider business mailing address

13618 RANIER DR
MIDDLEBURY IN
46540-8640
US

V. Phone/Fax

Practice location:
  • Phone: 574-875-6531
  • Fax:
Mailing address:
  • Phone: 641-208-7953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KIRSTINA GRATZ
Title or Position: MEMBER
Credential: DDS
Phone: 319-430-8601