Healthcare Provider Details

I. General information

NPI: 1366044158
Provider Name (Legal Business Name): GRAND LAKE FAMILY DENTISTRY TRAVIS D LUTZ DDS- ROCKFORD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 11/16/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E. WALNUT ST.
ROCKFORD OH
45882
US

IV. Provider business mailing address

160 E. WALNUT ST.
ROCKFORD OH
45882
US

V. Phone/Fax

Practice location:
  • Phone: 419-363-3537
  • Fax:
Mailing address:
  • Phone: 419-363-3537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. TRAVIS LUTZ
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 419-305-9983