Healthcare Provider Details

I. General information

NPI: 1871644989
Provider Name (Legal Business Name): LATHE EDWARD MILLER D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

847 PARCHMENT DR SE
GRAND RAPIDS MI
49546-2303
US

IV. Provider business mailing address

847 PARCHMENT DR SE
GRAND RAPIDS MI
49546-2303
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-9320
  • Fax: 616-942-1878
Mailing address:
  • Phone: 616-942-9320
  • Fax: 616-942-1878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number29010118731
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: