Healthcare Provider Details

I. General information

NPI: 1164548640
Provider Name (Legal Business Name): LAKE MICHIGAN DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 03/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 LAKE MICHIGAN DRIVE NW
GRAND RAPIDS MI
49504-4798
US

IV. Provider business mailing address

2150 LAKE MICHIGAN DRIVE NW
GRAND RAPIDS MI
49504-4798
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-8211
  • Fax: 616-453-3277
Mailing address:
  • Phone: 616-453-8211
  • Fax: 616-453-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateMI

VIII. Authorized Official

Name: MICHAEL SCOTT PALASZEK
Title or Position: PARTNER
Credential: DDS
Phone: 616-453-8211