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General NPI Number Information
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NPI Number | 1497077630
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Entity Type | Organization
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Legal Business Name | GREAT LAKES FAMILY DENTAL GROUP-LIVONIA, P.C.
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Dates
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Enumeration Date | 02/15/2010
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Last Update Date | 02/15/2010
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Provider Practice Location Address
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Address Line | 16160 MIDDLEBELT RD
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City | LIVONIA
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State | MI
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Zip | 48154-3338
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Country | US
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Telephone | 734-261-9696
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Fax |
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Provider Business Mailing Address
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Address Line | G3222 BEECHER RD
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City | FLINT
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State | MI
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Zip | 48532-3614
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Country | US
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Telephone | 810-230-3245
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Fax | 810-230-3229
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. C PATRICK GRAY
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Credential | D.D.S.
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Telephone | 810-732-0200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 122300000X
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 1223S0112X
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License Number State | MI
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