=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467636506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH LENNAN MASTERSON DDS, MSD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2007
-----------------------------------------------------
Last Update Date | 10/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4211 PARKWAY PLACE DR SW SUITE 104
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-2695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-249-3500
-----------------------------------------------------
Fax | 616-249-3502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4211 PARKWAY PLACE DR SW SUITE 104
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-2695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-249-3500
-----------------------------------------------------
Fax | 616-249-3502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 2901019457
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------