Healthcare Provider Details

I. General information

NPI: 1457178667
Provider Name (Legal Business Name): SEVA DENTAL MICHIGAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 4 MILE RD NW
GRAND RAPIDS MI
49544-7397
US

IV. Provider business mailing address

1100 4 MILE RD NW
GRAND RAPIDS MI
49544-7397
US

V. Phone/Fax

Practice location:
  • Phone: 616-784-6377
  • Fax:
Mailing address:
  • Phone: 616-784-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: KELLY ROLNICKI
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 708-372-4773