Healthcare Provider Details

I. General information

NPI: 1376923623
Provider Name (Legal Business Name): MARK GRINZINGER DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4349 SAWKAW DR NE
GRAND RAPIDS MI
49525-1768
US

IV. Provider business mailing address

4349 SAWKAW DR NE
GRAND RAPIDS MI
49525-1768
US

V. Phone/Fax

Practice location:
  • Phone: 586-576-4140
  • Fax:
Mailing address:
  • Phone: 616-361-7327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901021497
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: