Provider Demographics
NPI:1144726506
Name:GREAT LAKES PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:GREAT LAKES PEDIATRIC DENTISTRY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:STEINMETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-766-0085
Mailing Address - Street 1:15525 BARLEY RD NW
Mailing Address - Street 2:
Mailing Address - City:ROYALTON
Mailing Address - State:MN
Mailing Address - Zip Code:56373-8148
Mailing Address - Country:US
Mailing Address - Phone:320-766-0085
Mailing Address - Fax:
Practice Address - Street 1:219 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2236
Practice Address - Country:US
Practice Address - Phone:320-766-0085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND132371223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty