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General NPI Number Information
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NPI Number | 1073265542
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Entity Type | Organization
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Legal Business Name | GREAT LAKES DENTISTRY CHESTERFIELD
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Dates
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Enumeration Date | 01/25/2022
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Last Update Date | 01/25/2022
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Provider Practice Location Address
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Address Line | 34301 23 MILE RD STE 140A
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City | CHESTERFIELD
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State | MI
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Zip | 48047-4432
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Country | US
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Telephone | 586-725-5500
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Fax |
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Provider Business Mailing Address
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Address Line | 73501 WINDMILL DR
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City | BRUCE TWP
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State | MI
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Zip | 48065-3159
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. SHAWN VAN DE VYVER
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Credential |
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Telephone | 734-320-8939
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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