Basic Information
| Provider Information | |||||||||
| NPI: | 1457467839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEGROFF | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 LAPEER | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486071208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596464 | ||||||||
| FaxNumber: | 9893998233 | ||||||||
| Practice Location | |||||||||
| Address1: | 2308 WADSWORTH | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486011435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897547771 | ||||||||
| FaxNumber: | 9897548792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 06/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901019377 | MI | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | D801095 | 01 | MN | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER | 1457467839 | 05 | MI | MEDICAID | 381908328 | 01 | MI | DELTA DENTAL OF MICHIGAN | OTHER |