Healthcare Provider Details

I. General information

NPI: 1679963987
Provider Name (Legal Business Name): GREAT LAKES FAMILY DENTAL GROUP-CHARLOTTE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 W LAWRENCE AVE
CHARLOTTE MI
48813-1309
US

IV. Provider business mailing address

917 W LAWRENCE AVE
CHARLOTTE MI
48813-1309
US

V. Phone/Fax

Practice location:
  • Phone: 517-543-1840
  • Fax:
Mailing address:
  • Phone: 517-543-1840
  • 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: MRS. HELDA PALSHAN
Title or Position: ASSISTANT CORPORATE MANAGER
Credential:
Phone: 810-814-0204