Provider Demographics
NPI:1427452176
Name:DETTMANN CENTER
Entity type:Organization
Organization Name:DETTMANN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:DETTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-350-3230
Mailing Address - Street 1:3501 LAKE EASTBROOK BLVD SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5939
Mailing Address - Country:US
Mailing Address - Phone:616-350-3230
Mailing Address - Fax:
Practice Address - Street 1:3501 LAKE EASTBROOK BLVD SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5939
Practice Address - Country:US
Practice Address - Phone:616-350-3230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
4301051003207LA0401X
MI4301051003207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Single Specialty