Healthcare Provider Details

I. General information

NPI: 1487128120
Provider Name (Legal Business Name): DENTAL GROUP ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 CASCADE RD SE # B
GRAND RAPIDS MI
49546-8381
US

IV. Provider business mailing address

128 COLUMBUS AVE
GRAND HAVEN MI
49417-1224
US

V. Phone/Fax

Practice location:
  • Phone: 616-268-2090
  • Fax:
Mailing address:
  • Phone: 616-268-2092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LISA PAPES
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 616-268-2092