Provider Demographics
NPI:1174175996
Name:GRAND RIVER PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:GRAND RIVER PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGHAN
Authorized Official - Middle Name:DUBOIS
Authorized Official - Last Name:CONDIT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-250-4494
Mailing Address - Street 1:7758 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-8524
Mailing Address - Country:US
Mailing Address - Phone:616-777-3300
Mailing Address - Fax:
Practice Address - Street 1:7758 20TH AVE
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428
Practice Address - Country:US
Practice Address - Phone:734-250-4494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-11
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty