Provider Demographics
NPI:1548872518
Name:EAST LANSING ADVANCED DENTAL DBA EAST LANSING MODERN DENTAL
Entity type:Organization
Organization Name:EAST LANSING ADVANCED DENTAL DBA EAST LANSING MODERN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE DEVELOPMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-525-6100
Mailing Address - Street 1:2035 ASHER CT
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8480
Mailing Address - Country:US
Mailing Address - Phone:517-394-1495
Mailing Address - Fax:
Practice Address - Street 1:2035 ASHER CT
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8480
Practice Address - Country:US
Practice Address - Phone:517-394-1495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty