Provider Demographics
NPI:1386320257
Name:THE DENTAL HOUSE PLLC
Entity type:Organization
Organization Name:THE DENTAL HOUSE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROCKTON
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:WILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-266-2611
Mailing Address - Street 1:660 CROSWELL AVE. SE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506
Mailing Address - Country:US
Mailing Address - Phone:616-266-2611
Mailing Address - Fax:616-282-1709
Practice Address - Street 1:660 CROSWELL AVE. SE
Practice Address - Street 2:
Practice Address - City:EAST GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506
Practice Address - Country:US
Practice Address - Phone:616-266-2611
Practice Address - Fax:616-282-1709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental