Healthcare Provider Details

I. General information

NPI: 1235739533
Provider Name (Legal Business Name): RANDY J BREEN DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 BURTON ST SE STE 201
GRAND RAPIDS MI
49546-4800
US

IV. Provider business mailing address

2460 BURTON ST SE STE 201
GRAND RAPIDS MI
49546-4800
US

V. Phone/Fax

Practice location:
  • Phone: 616-454-9091
  • Fax:
Mailing address:
  • Phone:
  • 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: DR. RANDY BREEN
Title or Position: OWNER
Credential:
Phone: 616-454-9091