Healthcare Provider Details

I. General information

NPI: 1720685399
Provider Name (Legal Business Name): ELIAS DENTAL LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 GREENWOOD AVE SE STE 100
GRAND RAPIDS MI
49506-2901
US

IV. Provider business mailing address

535 GREENWOOD AVE SE STE 100
GRAND RAPIDS MI
49506-2901
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-2048
  • Fax: 616-458-1311
Mailing address:
  • Phone: 616-458-2048
  • Fax: 616-458-1311

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: RICHARD J ELIAS
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 616-458-2048