Provider Demographics
NPI:1316725096
Name:TAG ORTHODONTICS PLLC
Entity type:Organization
Organization Name:TAG ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-737-9401
Mailing Address - Street 1:5300 PATTERSON AVE SE STE 110
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9758
Mailing Address - Country:US
Mailing Address - Phone:616-283-8867
Mailing Address - Fax:
Practice Address - Street 1:4981 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2313
Practice Address - Country:US
Practice Address - Phone:315-487-3335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAG ORTHODONTICS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty