Healthcare Provider Details

I. General information

NPI: 1992541809
Provider Name (Legal Business Name): GRANT EGNATZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 N UNIVERSITY AVE
ANN ARBOR MI
48109-1078
US

IV. Provider business mailing address

609 W MADISON ST
ANN ARBOR MI
48103-4927
US

V. Phone/Fax

Practice location:
  • Phone: 734-764-1568
  • Fax:
Mailing address:
  • Phone: 336-413-9742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901602241
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: