Healthcare Provider Details

I. General information

NPI: 1699509166
Provider Name (Legal Business Name): DONASTORG DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10192 GRAND RIVER RD STE 104
BRIGHTON MI
48116-6516
US

IV. Provider business mailing address

4336 TUPPER LAKE WAY
LINDEN MI
48451-8469
US

V. Phone/Fax

Practice location:
  • Phone: 810-227-5136
  • Fax:
Mailing address:
  • Phone: 810-241-2959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. VANESSA DONASTORG
Title or Position: OWNER
Credential:
Phone: 810-241-2959