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General NPI Number Information
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NPI Number | 1427452176
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Entity Type | Organization
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Legal Business Name | DETTMANN CENTER
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Dates
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Enumeration Date | 10/09/2014
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Last Update Date | 09/27/2016
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Provider Practice Location Address
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Address Line | 3501 LAKE EASTBROOK BLVD SE STE 100
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-5939
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Country | US
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Telephone | 616-350-3230
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Fax |
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Provider Business Mailing Address
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Address Line | 3501 LAKE EASTBROOK BLVD SE STE 100
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-5939
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Country | US
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Telephone | 616-350-3230
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SANDRA K DETTMANN
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Credential | M.D.
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Telephone | 616-350-3230
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LA0401X
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Taxonomy Name | Addiction Medicine (Anesthesiology) Physician
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License Number | 4301051003
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License Number State |
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