Healthcare Provider Details

I. General information

NPI: 1225632284
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF EAST LANSING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3511 COOLIDGE RD
EAST LANSING MI
48823-6390
US

IV. Provider business mailing address

3511 COOLIDGE RD
EAST LANSING MI
48823-6390
US

V. Phone/Fax

Practice location:
  • Phone: 517-337-0032
  • Fax:
Mailing address:
  • Phone: 517-337-0032
  • 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. JACOB MYERS
Title or Position: DENTIST
Credential: DDS, FAAPD
Phone: 517-337-0032