Healthcare Provider Details

I. General information

NPI: 1184578221
Provider Name (Legal Business Name): STANDALE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2026
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3935 LAKE MICHIGAN DR NW STE 2
GRAND RAPIDS MI
49534-7844
US

IV. Provider business mailing address

3935 LAKE MICHIGAN DR NW STE 2
GRAND RAPIDS MI
49534-7844
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-7755
  • Fax: 616-453-3103
Mailing address:
  • Phone: 616-453-7755
  • Fax: 616-453-3103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROBERT GERALD MULL
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 616-453-7755