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General NPI Number Information
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NPI Number | 1518269877
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Entity Type | Organization
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Legal Business Name | GRAND RIVER ORTHODONTICS, PC
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Dates
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Enumeration Date | 11/18/2010
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Last Update Date | 11/18/2010
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Provider Practice Location Address
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Address Line | 1335 W MAIN ST SUITE D
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City | LOWELL
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State | MI
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Zip | 49331-1555
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Country | US
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Telephone | 616-897-0200
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Fax |
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Provider Business Mailing Address
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Address Line | 1335 W MAIN ST SUITE D
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City | LOWELL
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State | MI
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Zip | 49331-1555
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Country | US
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Telephone | 616-897-0200
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/ORTHODONTIST
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Name | HEATHER GIETZEN
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Credential |
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Telephone | 616-879-0200
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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 | 2901018802
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License Number State | MI
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