Provider Demographics
NPI:1801319025
Name:GRANT K. GILLISH D.D.S., P.L.L.C.
Entity type:Organization
Organization Name:GRANT K. GILLISH D.D.S., P.L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-893-2915
Mailing Address - Street 1:116 W COLBY ST STE 1
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-1084
Mailing Address - Country:US
Mailing Address - Phone:231-893-2915
Mailing Address - Fax:
Practice Address - Street 1:116 W COLBY ST STE 1
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-1084
Practice Address - Country:US
Practice Address - Phone:231-893-2915
Practice Address - Fax:231-893-4719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020310122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty