Provider Demographics
NPI:1316714728
Name:WILLOW RIVER DENTAL PLLC
Entity type:Organization
Organization Name:WILLOW RIVER DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LATENDRESSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-201-0852
Mailing Address - Street 1:625 E LIBERTY ST STE 202
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2013
Mailing Address - Country:US
Mailing Address - Phone:734-668-6612
Mailing Address - Fax:
Practice Address - Street 1:625 E LIBERTY ST STE 202
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2013
Practice Address - Country:US
Practice Address - Phone:734-668-6612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center