Healthcare Provider Details

I. General information

NPI: 1508799594
Provider Name (Legal Business Name): GRAND RIVER DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 MENTOR AVE STE 110
MENTOR OH
44060-8712
US

IV. Provider business mailing address

1034 W JACKSON ST
PAINESVILLE OH
44077-2529
US

V. Phone/Fax

Practice location:
  • Phone: 435-313-1302
  • Fax:
Mailing address:
  • Phone: 435-313-1302
  • Fax:

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: JAMIE C KISER
Title or Position: OFFICE MANAGER
Credential:
Phone: 435-313-1302