Provider Demographics
NPI:1174141741
Name:GOOD TO GROW DENTAL CENTER, PLLC
Entity type:Organization
Organization Name:GOOD TO GROW DENTAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRSTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRATZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-430-8601
Mailing Address - Street 1:13618 RANIER DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-8640
Mailing Address - Country:US
Mailing Address - Phone:641-208-7953
Mailing Address - Fax:
Practice Address - Street 1:21781 OMEGA CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-7809
Practice Address - Country:US
Practice Address - Phone:574-875-6531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty