Healthcare Provider Details

I. General information

NPI: 1427769934
Provider Name (Legal Business Name): GRAND RIDGE FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 GRAND RIDGE DR NE
GRAND RAPIDS MI
49525-7071
US

IV. Provider business mailing address

3350 GRAND RIDGE DR NE
GRAND RAPIDS MI
49525-7071
US

V. Phone/Fax

Practice location:
  • Phone: 810-341-3642
  • Fax:
Mailing address:
  • Phone: 810-341-3642
  • 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. RYAN KEENER
Title or Position: DENTIST
Credential: DDS
Phone: 810-341-3642