Healthcare Provider Details

I. General information

NPI: 1730238577
Provider Name (Legal Business Name): GREAT LAKES DENTAL CARE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 3 MILE RD NW STE 110
GRAND RAPIDS MI
49544-1673
US

IV. Provider business mailing address

933 3 MILE RD NW STE 110
GRAND RAPIDS MI
49544-1673
US

V. Phone/Fax

Practice location:
  • Phone: 616-784-6300
  • Fax:
Mailing address:
  • Phone: 616-784-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901019180
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901011152
License Number StateMI

VIII. Authorized Official

Name: DR. DENNIS BRUCE WEBB
Title or Position: DENTIST
Credential: D.D.S.
Phone: 616-784-6300