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General NPI Number Information
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NPI Number | 1639030307
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Entity Type | Organization
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Legal Business Name | LEGACY DENTAL ASSOCIATES
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Dates
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Enumeration Date | 11/20/2025
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Last Update Date | 11/20/2025
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Provider Practice Location Address
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Address Line | 2440 GAYNOR AVE NW
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City | GRAND RAPIDS
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State | MI
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Zip | 49544-1830
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Country | US
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Telephone | 616-784-8444
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Fax |
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Provider Business Mailing Address
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Address Line | 2716 STERNER ST NW
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City | GRAND RAPIDS
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State | MI
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Zip | 49504-8100
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Country | US
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Telephone | 616-558-7928
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. JAKOB LEE
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Credential | DDS
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Telephone | 616-558-7928
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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 |
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License Number State |
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