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General NPI Number Information
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NPI Number | 1700269735
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Entity Type | Organization
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Legal Business Name | GANTZ DDS PLLC
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Dates
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Enumeration Date | 07/08/2015
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Last Update Date | 04/12/2016
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Provider Practice Location Address
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Address Line | 25865 W 12 MILE RD
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City | SOUTHFIELD
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State | MI
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Zip | 48034-1817
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Country | US
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Telephone | 248-353-4010
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Fax | 248-353-0829
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Provider Business Mailing Address
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Address Line | 25865 W 12 MILE RD
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City | SOUTHFIELD
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State | MI
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Zip | 48034-1817
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Country | US
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Telephone | 248-353-4010
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Fax | 248-353-0829
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Authorized Official
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Title or Position | OWNER
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Name | ELAINE K GANTZ
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Credential | DDS
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Telephone | 248-353-4010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901013299
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License Number State | MI
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