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General NPI Number Information
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NPI Number | 1336782135
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Entity Type | Organization
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Legal Business Name | GREAT LAKES BAY ORTHODONTICS, PLC
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Dates
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Enumeration Date | 10/24/2019
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Last Update Date | 10/24/2019
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Provider Practice Location Address
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Address Line | 200 NORTHGATE DR
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City | MIDLAND
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State | MI
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Zip | 48640-7344
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Country | US
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Telephone | 989-631-1334
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Fax |
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Provider Business Mailing Address
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Address Line | 200 NORTHGATE DR
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City | MIDLAND
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State | MI
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Zip | 48640-7344
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Country | US
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Telephone | 989-631-1334
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Fax |
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | ANDREW GRILLO
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Credential | DDS, MSD
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Telephone | 989-600-8037
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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