Provider Demographics
NPI:1396316964
Name:GREIDANUS, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GREIDANUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1439
Mailing Address - Country:US
Mailing Address - Phone:616-669-6600
Mailing Address - Fax:
Practice Address - Street 1:3250 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1439
Practice Address - Country:US
Practice Address - Phone:616-669-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601075122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist