Healthcare Provider Details

I. General information

NPI: 1194421909
Provider Name (Legal Business Name): AFFINITY DENTAL CARE PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 LAKE MICHIGAN DR NW STE 3
GRAND RAPIDS MI
49504-5831
US

IV. Provider business mailing address

PO BOX 141547
GRAND RAPIDS MI
49514-1547
US

V. Phone/Fax

Practice location:
  • Phone: 678-462-0499
  • Fax:
Mailing address:
  • Phone: 404-207-2605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MANUEL R ALE
Title or Position: OFFICE MANAGER
Credential: MBA
Phone: 404-207-2605