=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487568895
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LITTLE ROOTS PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2026
-----------------------------------------------------
Last Update Date | 10/01/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3810 32ND AVE STE 500
-----------------------------------------------------
City | HUDSONVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49426-8554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-777-3206
-----------------------------------------------------
Fax | 616-777-5305
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3810 32ND AVE STE 500
-----------------------------------------------------
City | HUDSONVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49426-8554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-777-3206
-----------------------------------------------------
Fax | 616-777-5305
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PEDIATRIC DENTIST
-----------------------------------------------------
Name | JENNIFER LUCA
-----------------------------------------------------
Credential | DMD, MD
-----------------------------------------------------
Telephone | 248-882-2350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------