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General NPI Number Information
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NPI Number | 1174141741
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Entity Type | Organization
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Legal Business Name | GOOD TO GROW DENTAL CENTER, PLLC
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Dates
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Enumeration Date | 07/10/2020
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Last Update Date | 07/10/2020
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Provider Practice Location Address
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Address Line | 21781 OMEGA CT
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City | GOSHEN
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State | IN
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Zip | 46528-7809
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Country | US
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Telephone | 574-875-6531
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Fax |
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Provider Business Mailing Address
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Address Line | 13618 RANIER DR
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City | MIDDLEBURY
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State | IN
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Zip | 46540-8640
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Country | US
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Telephone | 641-208-7953
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. KIRSTINA GRATZ
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Credential | DDS
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Telephone | 319-430-8601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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