Healthcare Provider Details

I. General information

NPI: 1316253149
Provider Name (Legal Business Name): GREAT LAKES DENTALOF WESTLAKE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25101 DETROIT RD SUITE 445
WESTLAKE OH
44145-2552
US

IV. Provider business mailing address

19111 DETROIT RD STE 206
ROCKY RIVER OH
44116-1740
US

V. Phone/Fax

Practice location:
  • Phone: 440-617-9429
  • Fax: 440-617-9457
Mailing address:
  • Phone: 440-617-9429
  • Fax: 440-356-2090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number022436
License Number StateOH

VIII. Authorized Official

Name: STAFANI SANDOVAL
Title or Position: INSURANCE SPECIALIST
Credential:
Phone: 440-356-2089