Provider Demographics
NPI:1073702478
Name:GRATIOT DENTAL PC
Entity type:Organization
Organization Name:GRATIOT DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-527-1140
Mailing Address - Street 1:12645 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-3952
Mailing Address - Country:US
Mailing Address - Phone:313-527-1140
Mailing Address - Fax:313-527-9022
Practice Address - Street 1:12645 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-3952
Practice Address - Country:US
Practice Address - Phone:313-527-1140
Practice Address - Fax:313-527-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI12881122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty