Healthcare Provider Details

I. General information

NPI: 1720173529
Provider Name (Legal Business Name): LONNY E ZIETZ D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-4785
US

IV. Provider business mailing address

2140 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-4785
US

V. Phone/Fax

Practice location:
  • Phone: 616-791-9600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901009665
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: