Provider Demographics
NPI:1386388114
Name:GRASS LAKE DENTAL CENTER PLLC
Entity type:Organization
Organization Name:GRASS LAKE DENTAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUCIANA
Authorized Official - Middle Name:GABRIELA
Authorized Official - Last Name:CASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-355-0779
Mailing Address - Street 1:2143 ORCHARDVIEW
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-2766
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11745 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-9219
Practice Address - Country:US
Practice Address - Phone:517-522-5018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental