Provider Demographics
NPI:1053199141
Name:GREAT LAKES DENTAL GROUP PLLC
Entity type:Organization
Organization Name:GREAT LAKES DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-547-3700
Mailing Address - Street 1:4251 COOLIDGE HWY
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-1639
Mailing Address - Country:US
Mailing Address - Phone:248-547-3700
Mailing Address - Fax:248-547-2297
Practice Address - Street 1:4251 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1639
Practice Address - Country:US
Practice Address - Phone:248-547-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty