# MODERN FAMILY DENTAL PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1003479833
- **Authorized official:** RENEE HEISE (INSURANCE SPECIALIST)
- **Authorized official phone:** (231) 865-6945

## Contact information

- **Practice address:** 17272 ROBBINS RD STE 104, GRAND HAVEN, MI 49417-2677
- **Practice address phone:** (616) 820-5744
- **Mailing address:** 17272 ROBBINS RD STE 104, GRAND HAVEN, MI 49417-2677
- **Mailing address phone:** (616) 820-5744

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 04/17/2019
- **Last updated:** 04/17/2019