Provider Demographics
NPI:1912146978
Name:WOODLAND LAKE FAMILY DENTAL, PLLC
Entity type:Organization
Organization Name:WOODLAND LAKE FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-233-7475
Mailing Address - Street 1:8127 GRAND RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-9375
Mailing Address - Country:US
Mailing Address - Phone:810-229-6740
Mailing Address - Fax:810-225-2344
Practice Address - Street 1:8127 GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9375
Practice Address - Country:US
Practice Address - Phone:810-229-6740
Practice Address - Fax:810-225-2344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-16
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty